Introduction

Pyelonephritis is a potentially organ and/or life-threatening infection which causes some

scarring of the kidney with each infection and may lead to significant damage to the kidney (any

given episode), such as, kidney failure, abscess formation, sepsis, or sepsis

syndrome/shock/multi organ system failure.

Diagnosing and managing acute pyelonephritis is not that simple. In the age range of 5-6

years, it typically presents in the context of a symptomatic urinary tract infection (UTI) with

classic upper urinary tract symptoms like Flank pain and lower back pain with or without

systemic symptoms like fever, chills, abdominal pain, nausea, vomiting and signs like costo-

vertebral angle tenderness with or with out leukocytosis. However, it can present with non

specific symptoms.

A number of studies using immunochemical markers have shown that many women, who

initially present with lower tract symptoms, actually have pyelonephritis. These groups of young

women are often identified when short-course therapy for uncomplicated cystitis fails. In the

extremes of age, the presentation may be so atypical that pyelonephritis is not in the differential

diagnosis. In the infant, the presentation may be feeding difficulty or fever. In the elderly, the

presentation may be mental status change or fever.

Chief Complaint
Abdominal Pain
Risk Factor Assessment

Non-Modifiable
 Age
 Gender
 Race
 Family History
Modifiable
 Diet
 Lifestyle
 Elimination

Gordon’s Functional Assessment

I. Demographic Data (Biographical Data)
Client’s Name or Initial: Min, Jin
Age: 14
Sex: Female
Civil Status: Single
Religion: Protestant
Address: 213B San Nicholas Molino, Bacoor, Cavite
Telephone Number: 875-15-46
Race/Nationality: Korean
Usual source of medical care: University of Perpetual Help System Dalta
Source and reliability of information: Patient

II. Reasons for seeking health:

- Consultation for present illness

- Seeking help assistance
 III. History

A. Medical History
• Pediatric / Childhood / Adult illness – Urinary Tract Infection
• Injuries or Accidents – None
• Hospitalization – None
• Obstetric History (for female clients only) – N/A
• Immunization –

BCG: (/) at birth (/) school entrance

DPT: (/) 1st dose (/) 2nd dose (/) 3rd dose
OPV: (/) 1st dose (/) 2nd dose (/) 3rd dose
AMV:
TT: ( ) 1st dose ( ) 2nd dose ( ) 3rd dose ( ) 4th dose ( ) 5th dose
Hepa B: (/) 1st dose (/) 2nd dose (/) 3rd dose
Others (varicella vaccine, influenza vaccine.):
_____________________________________________________________________________
___________________________________________________________________

• Allergies:
Food, specify: none
Drugs, specify: none
Chemicals, specify: none
Environmental Allergies, specify: none

B. Family History

Mother Father
- History of kidney
Infection

Min, Jin

IV. Functional Assessment (narrative presentation)

1) Health Perception and health management pattern. (describes how persons perceive
patterns of health and well-being and how health is managed)
- Our client stated that despite her frequent night out with friends and drinking at
least 3 – 5 bottles of alcohol, she still values her health by refraining from learning to
smoke and doing drugs.
-
2) Self esteem, self concept, self perception pattern. (describes how persons perceive
themselves, their capabilities, body image and feelings)
- Our client stated that she is not a shy person. She goes out to party with friends and
to meet up with new ones. She is very confident of her physical appearance although
she doesn’t approve of her height. She likes to join school activities like playing
soccer, and being a part of the high school officers. In fact, she is in one of the pilot
sections of the 2nd yr high school of perpetual help.

3) Activities/exercise pattern. (describes pattern of exercise, activity , leisure and recreation,

includes activities of daily living, type and quality of exercise and factors affecting
activity pattern)
- She goes to school from Mondays to Fridays and attends soccer practice after school
hours. She also told us that sometimes school work gets in her way when soccer
practice is being called for. And during weekends she is out with her friends
partying and drinking.

4) Nutritional and metabolic pattern. (describes consumption relative to metabolic needs and
nutrient supply; includes pattern of food and fluid consumption, condition of hair, nails
mucous membrane, body temperature, height and weight)
- Our client said that she eats a complete meal 3 times a day, sometimes more, and she
sees to it that she drinks a lot of water. And before she sleeps, she never forgets to
take a bath.

5) Elimination pattern (describes patterns of excretory function – bowel bladder and skin;
includes individual’s daily pattern, changes and disturbances)
- Our client said that there are no irregularities regarding her elimination pattern.
Normal bowel elimination once or twice a day.

6) Sleep and rest pattern (describe patterns of sleep, rest and relaxation)
- Our client said that sometimes during weekdays she would only have 5 hours left for
sleeping depending on the number of homework’s that are due on the next day. And
during the weekends, she would sleep up until 12 in the afternoon so as to regain her
strength and party with her friends.

7) Cognitive – perceptual pattern (describes sensory – perceptual and cognitive patterns;

includes adequacy of sensory modes: vision, hearing, touch, taste and smell: reports of
pain perception and cognitive functional abilities)
- Our client has no difficulty in hearing words that are near or that surrounds her
and can pick sounds from outside her room. She can see things clearly that are 20
feet away from her and so as those from afar, her peripheral visions are also clearly
seen. She reacts to needles and IV medicines that are to given to her. And complains
of pain in her right dorsum hand where her IV site can be seen.
 8) Role relationship pattern (describes pattern of role engagements and relationships;
includes perception of major roles and responsibilities in current life situation)
- Our client being the only child in her family doesn’t put her into too much pressure.
She can have the materials or the latest gadgets she wants, she is allowed to date
Filipino boys (she is korean), and that she has a wide range of friends from high
school to college.

9) Sexuality reproductive pattern (describes patterns of satisfaction or dissatisfaction with

sexuality; includes female reproductive state)
- Our client said that she has not yet engaged herself to premarital sex.

10)Coping stress tolerance pattern (describes general coping pattern and effectiveness of
coping skills in stress tolerance)
- Our client had related to us a tragedy that had happened before to her friend that
died last year because of a car accident. She was devastated but quickly learned
that even though it happened, life still goes on to those who lives.

11)Value Belief pattern (describes patterns of value, goals or beliefs that guide lifestyle
choices and decisions)
- Our client does not have any particular cultural beliefs. Her motto was as long as
you don’t step on others and as long as you are happy you’ll be okay.

V. Physical Assessment

SYSTEM WHAT TO ASSESS ACTUAL FINDINGS

A. Vital Signs • Temperature, pulse, Temp:35C
respiration, blood Pulse: 78 bpm
pressure RR: 18 cpm
BP: 100/60 mmHg
B. Integumentary
1. Skin • Color, odor, • Pinkish white. No
temperature, odor. Increased in
moisture, texture, normal temp. Good
thickness, mobility, skin turgor. No
turgor, vascularity, swelling. No lesions.
swelling, rashes No rashes. Clear
skin.
2. Hair • Distribution, • Evenly distributed
thickness, texture, hair. Thick hair.
lubrication, scalp Shiny hair. No
characteristics dandruff. No lice
infestation.
3. Nails • Nail bed color, • Convex curvature of
consistency, nail. Smooth and
 thickness, shape, even texture. Good
texture, angle capillary refill.
between nail and Intact epidermis. No
nail bed, capillary lesion.
refill
C. Head and Neck
1. Head • Size, shape, contour • Smooth skull
contour. No
inflamed nodules.
Symmetrical shape.
2. Eyes • Visual acuity, extra • Can see objects
ocular movement, periphery. 20/20
visual fields, visual acuity. Both
position and eyes coordinated.
alignment. Symmetrical in
position.

• Eyebrows: • - Eyebrows are

symmetry, symmetrically
movement, aligned. Equal
extension, quantity movement. Skin
of hair. intact.

• Eyelashes: • Eyelashes equally

distribution. distributed, curled
slightly outward.

• Eyelids: position • No edema or

and movement anything discharged

• Conjunctiva: color • Red conjunctiva

• Pupils: equality, • PERRLA ( pupils

shape, reaction to equally round
light, reactive to light
accommodation accomodation )

3. Ears
• Auricle: position, • Symmetrical
size, texture, shape auricles aligned with
outer canthus of
eyes.
• External auditory • Dry cerumen, slight
canal: discharge or yellowish in color.
 cerumen’s color,
consistency

• Hearing acuity • Normal hearing. No

lesion.

4. Nose
• External nose: shape • Symmetrical,
symmetry, texture, uniform in color, no
skin color. lesions.
• Nares: shape, • No discharge, no
symmetry, discharge flaring.
• Mucosa: color, • Mucosa color pink,
discharge no discharge
• Septum: symmetry • Septum
symmetrical, no
lesion.
• Sinus: texture • Sinus not tender

5. Mouth
• Lips: color, texture, • Pink in color, no
hydration, contour. lesions, moist,
symmetrical

• Teeth: position, • 32 adult teeth, white

color, hygiene teeth.
• Tongue: color, • Tongue moves freely
position, texture, and no tenderness or
coating, mobility lesions

• Gums: color, texture • No retraction of

gums, no lesions, no
inflammations

• Pharynx: color, • pinkish

6. Neck
hydration

• Mobility • Muscles equal in

size, smooth
movement
• Thyroid gland: • No discomfort when
movement size moving
• Lymph nodes: • No palpable lymph
 number, size, nodes
location, consistency
• Veins: fillings, • No enlargement
pulsation
D. Thorax and Lungs

• Shape, symmetry • Symmetrical

• Chest excursion or • Full and
movement symmetrical chest
expansion
• RR and rhythm • 21 cycles per minute
• Position of spine, • Symmetrical
lope of ribs, position of ribs
symmetry of scapula • Vesicular sounds
and costal angle auscultated
• Tactile fremitus or • Bilateral symmetry
lung vibration of vocal fremitus
• Use of accessory • Symmetrical chest
muscle expansion and
relaxation
E. Breast and Axillas

• Size, symmetry,
skin, color, contour,
shape
• Venous pattern
• Moles and other
markings
• Areola: size, shape,
surface
characteristics
• Nipples: size, shape,
surface
characteristics and
discharge
• Lymph nodes on
each axilla: location,
number, size and
mobility.
F. Heart
• No pulsation to the
• Appearance of side
pulsation • No lift or
• Apical pulse or irregularities
 PMI: location,
strength and
synchrony with
carotid pulse
• Abdominal aorta • Abdominal pulsation
strength heard by
auscultation

• Heart sounds: • Regular rhythm

rhythm, rate
loudness
G. Abdomen

• Contour, symmetry • Unblemished skin,

no lesions
• Bowel sounds • Absent
• Percussion notes • Symmetrical
• Surface • audible bowel
characteristics sounds
distention
• Umbilicus: position, • Tymphany over the
shape, color stomach
• Normal respiratory • No tenderness
movement
H. Genitourinary

• Male: position of
scrotum, penis
opening, veins
• Female: distribution • Evenly distributed
of the pubic hair, pubic hair. No
condition of the lesions, no signs of
majora and minora infestation, smooth
lavia, presence of texture, no
infestation, texture, discharges or foul
skin color, odor.
discharges, odor.
• Anus and perineal
I. Musculoskletal

• Gait, stance, posture • equal size of muscle

• Backbone on left and right side
of the body
• Extremities,
• firm, no
alignment, position.
 • Muscle strength
• Range of motion
• Muscle coordination
J. Neurologic
fasciculation, no
tremors
• moves freely, good
coordination, can
tolerate full ROM

• Level of
consciousness: • impaired posture
language, response and balance, walks
to stimulation, unaided
intellectual function, • Able to walk and do
abstract thinking, ADL. Performs with
ability to perform coordination and
simple arithmetic rapidity
calculations, make • performs with
judgment accuracy
• demonstrates non-
bilateral equal
coordination
• able to verbalize her
feelings
• recognizes common
objects
• Able to identify
numbers and letters.

Diagnostics and Laboratory Results

The following are the deviations from normal that were gathered from the patients diagnostic
and laboratory results:

Lab Exams Result Normal Description Elevated Value Decreased Value

values might Mean might mean

BUN 2.0 Male Blood urea Impaired renal Impaired absorption

mmol/L nitrogen an function, shock, ie. cleiac disease,
8-25 mg/dl
2.9-8.9 improtant indicator congestive heart liver failure r/t
mmol/ of renal function failure, salt & water hepatits, poisoning,
literbun but not as sensitive depletion, excessive drugs, malnutrition,
as creatinine protein intake or acromegly,
Female
clearance test. In catabolism, stress, syndrome of
 8-25 mg/dl chronic renal hemorrhage with GI inappropriate
2.9-8.9 failure BUN tract, acute MI secretion of
mmol/liter correlates better PANIC value antidiuretic
Child with symptoms of >100mg/dl hormone, anabolic
uremia rather than steroid use, IV
5-18 mg/dl serum creatinine feedings with
1.8-6.4
overhydration
mmol/L

RBC 4.41 Male A blood test for Polycythemia, Anemia,

million/ RBC count, looks erythrocytosis,second lymphomas,leukemi
4.3–5.9
mm3 million/mm3 at the size, number, ary erythrocytosis in as, addison's,
rate of production many diseases, endocarditis,
Female and composition ; dehydration, lupus,rheumatic
the main function Gaisbock's syndrome, fever
4.5–5.5
million/mm3 of RBCs is to carry stress, overuse of
oxygen from the diuretics
lungs to the body
tissues and transfer
carbon dioxide
from the tissues
back to the lungs

Hct 0.36 Male 43- Part of the Severe dehydration, Anemias, acute
53% complete blood polycemia, massive blood loss,
count and testing is erythrocytosis cirrhosis, leukemia
Female 37- done to determine Again this test should Again this test
47% red blood cell mass be analyzed with should be analyzed
to determine other LAB results for with other LAB
Child 1-6yo
anemia or proper diagnosis results for proper
30-40%
polycythemia. This Hct >60% found with diagnosis Hct
test along with the clotting of blood
hemoglbin and
RBCs are assessed
to determine
diagnosis

WBC 12.8 Male Leukcocytes help There are 5 different AKA Leukopenia
3800– fight infection in types of leukocytes found in viral
9800/mcl the body and also rarely does an infections,
3.8–9.8 x help with the increase in one cause overwhelming
10^9/L immune system. all or another to bacterial or some
WBC count is increase where the bacterial infections,
useful in main increase is will primary bone
Female determining the be given the type of disorders, bone-
3800– severity of an leukocyte that is marrow depression
9800/mcl infection /disease affected:lymphocytosi due to medications,
3.8–9.8 x s neutrophilia hyperspleenism,
10^9/L esinophilia iron deficiency
monocytosis and anemia, immune
basophilia assoct.neutropenia,
An increase in fungal infection,
Child 6-
leukocytes occurs in metastic tumor
18yo 4.8-
acute infections Panic level less than
10.8
leukemia drugs 0.5
trauma accidental or
surgical after
splenectomy acute
hemorrhage
polycythemia acute
hemolysis tissue
necrosis
Leukocytosis with
NO symtoms of
disease: stress
exercise cold heat
pain excitement
anesthesia sunlight
UV irradiation
seizures nausea and
vomiting steroid
therapy blood
disorders;myeloprolif
erative disorders
recovery from bone
marrow suppression
asplenia
Panic lelvel >30.0
Clinical Findings / Signs & Symptoms

 (+) Abdominal Pain

 (+) Direct Tenderness @ the ® Quadrant
 (+) Rebound Tenderness
 (+) Flank Pain @ the RLQ
 (+) Dysuria
 (+) Bowel Movement
 (+) Kidney Punch @ ®
 Hyper active Bowel Sounds
 (+) Psoa’s Sign
 (+) Obturator Sign
 (+) Nausea
 (+) Weight Loss
 (+) Vomiting
 (+) Dizziness
 (+) Difficulty of Breathing

Problem List Prioritization

1) Hyperthermia
2) Pain
3) Impaired Urinary Elimination
4) Alteration in Comfort

Nursing Diagnosis

1. Hyperthermia R/T inflammatory process AEB increased body temperature

2. Acute Pain R/T acute inflammation of renal tissue AEB verbal report and guarding
behavior
3. Impaired Urinary Elimination R/T inflammation of bladder mucosa AEB Dysuria,
urgency and frequency
4. Alteration in Comfort R/T present condition
 Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
>No Verbal cues >Hyperthermia >After Nursing >Monitor vital >To have baseline >Goal met
R/T inflammatory interventions, the signs data and monitor >The patient
Objective: process AEB increased body patients progress maintain core
>In a Supine Body temperature temperature of the temperature
position patient will within normal
>Weak decrease or will >Administer >To control range with
>Pale obtain normal medication as shivering and latest
>Warm to touch body temperature ordered seizures and to temperature of
>Febrile- 38.4º C range treat underlying 35.4 º C
cause

>Provide >To offset

supplemental increased oxygen
oxygen demands and
consumption

>Administer >To support

replacement circulating
fluids and volume and tissue
electrolytes perfusion

>Keep patient >To be

on Bed rest comfortable and
to reduce
metabolic
demands

>Advise parent >To promote

to do TSB surface cooling

> Measure and >To monitor if

record Intake there is a balance
and output between Intake
and output
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective
>”Ang sakit ng likod >Acute Pain >At the end >Assess pain: >to rule out >Goal partially met.
kapag natayo at R/T acute of the nursing -pain scale worsening of >Pain was only
naihi” inflammation intervention, -location underlying relieved when the
>painscale of 8/10 of renal tissue the patient -when pain is condition or medication was
As verbalized by the AEB verbal will be able felt development of given.
patient report and to verbalize -when pain is complications
guarding lesser pain or relieved
Objective behavior achieve a
>In a supine position pain free >Monitor > To have
>(+) Guarding feeling Vital signs baseline data
behavior and monitor
>(+) facial grimace patients
>slow movement progress

>Provide >to promote

comfort non
measures like pharmacological
repositioning Pain
or use of heat management
or cold packs

>Administer >to maintain

analgesics as acceptable level
indicated to of pain
maximum
dosage as
needed

>Encourage >to prevent

adequate rest fatigue
periods

>Monitor > To monitor if

input and there is a
output balance between
Intake and
 output

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective
>”Masakit at mahapdi >Impaired >At the end >Assess pain: >to assist in >Goal partially
kapag umiihi ako, urinary of the nursing -pain scale differentiating met.
kaya nagpipigil ako.” elimination r/t intervention, -location between bladder >Pain was only
-duration and kidney as cause
As verbalized by the to irritation the patient relieved when the
-intensity of dysfunction
patient and will be able to medication was
-presence of
inflammation achieve bladder spasm > To have baseline given.
Objective of bladder normal data and monitor
>In a supine position mucosa as elimination >Monitor Vital patients progress
>(+) Guarding evidenced by pattern signs
behavior dysuria
>(+) facial grimace >to prevent fatigue
>(+) urinary
incontinency
>Encourage > To monitor if
adequate rest there is a balance
periods between Intake and
output

>Monitor input >to help determine

and output level of hydration

> for comparison

with current
situation
>Determine
clients usual
daily fluid >to reduce risk of
intake
infection of
>Ascertain autonomic
clients hyperreflexia
previous
pattern of
elimination

>Check
frequently for
bladder

Discharged Planning
These are the discharge plans prepared to promote wellness to the patient after her stay in
the Hospital:
Plan
• Encouraged proper hand hygiene.
• Encouraged to drink frequently
(cranberry juice has been shown to
reduce the incidence of cystitis) and
go on the bathroom as needed.
• Taught to wipe from front to back
after urination.
• Suggest limiting intake of coffee/tea
and alcohol.
• Advised to take the medications on
time – as prescribe by the doctor.
• Encouraged to increase fluid intake.
• When there’s an abdominal pain use
a hot or warm water bottle.
• Advise to take a shower rather than
bathe in tub.
• Advise to void every 2-3 hours
during the day and complete
emptying the bladder.
• Advise to avoid use of harsh soaps,
bubble bath, powder or sprays in
the perineal area.
distention and
observe for
overflow
Rationale
• To reduce the number of transient
microorganisms.
• To wash out microorganisms that
may ascends the urethra.
• To avoid contamination of the
urethral opening with fecal bacteria.
• It may irritate the bladder.
• To ensure to have the best possible
results from of treatment.
• This helps wash out germs from the
urinary system.
• To relieve the pain.
• Because bacteria in bathe may enter
the urethra.
• It prevents over distention of the
bladder and compromised blood
supply to the bladder wall which
predispose the patient to UTI.
• It can cause irritation to the urethra
and encourage inflammation and
bacterial infection.
• Accumulation of perineal moisture
 • Advise to wear cotton rather than facilitates bacterial growth and
nylon underwear. cotton underwear’s enhances
ventilation on the perineal area.

References
• http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2531093

• http://www.healthscout.com/ency/68/508/main.html

• http://en.wikipedia.org/wiki/Pyelonephritis

• www.brunnerandsudartt.com

• www.mims.com

• Dancel, Louella A., Laboratory Manual and Work Book In Microbiology And
Parasitology. Exercise no. 2 and 3, pages 11 - 21.

• Daniels, Rick et al., Contemporary Medical Surgical Nursing Vol.2, (2007)

pages 1777-1780

• Lippincott, Williams. Nursing 2008 Drug Handbook. (2008)

• Wilson, Billie Ann et al., Nurses Drug guide Vol. 1, 2004

CASE PRESENTATION

Pyelonephritis

Presented by:

Advincula, Roberto Miguel

Agban, Serwin Gino

Agbay, Janelle Marisse

Agcaoili, Maureen Grace

Aguedan, Arthur Jake

Aguilar, Homero

Aguilar, Jemelyn

Aguilar, Reina Loiza

Aguinaldo, Acelyn

Alagos, Ronalyn

Alavazo, Rommel John

 Ale Ale, Princess Grace

BSN 4A/ Group 3

Clinical Instructor: Ms. Michelle Seguerra R.N.