I.

INTRODUCTION

Acute pyelonephritis is a urinary tract infection that has progressed from

the lower urinary tract to the upper urinary tract. Most episodes of acute
pyelonephritis are uncomplicated but hospitalization may be required .

Pyelonephritis is an ascending urinary tract infection that has reached the

pyelum (pelvis) of the kidney (nephros in Greek). If the infection is severe, the
term "urosepsis" is used interchangeably (sepsis being a systemic inflammatory
response syndrome due to infection). It requires antibiotics as therapy, and
treatment of any underlying causes to prevent recurrence. It is a form of
nephritis. It can also be called pyelitis. Most kidney infections result from lower
urinary tract infections, usually bladder infections. Bacteria can travel from the
vagina or anus into the urethra and bladder. Because of the location and size of
their urethra, women are more prone to have bladder infections than men. In
both men and women, lower urinary tract infections may spread to the kidneys,
causing pyelonephritis.

Congenital abnormalities of the genito-urinary system and also kidney stones can
predispose people to get pyelonephritis.

acute uncomplicated pyelonephritis include flank pain, abdominal or pelvic pain,

nausea, vomiting, fever (≥37.8ºC), and/or costovertebral angle tenderness. Fever
has been strongly correlated with the diagnosis of acute pyelonephritis; thus,
patients with clinical manifestations of acute pyelonephritis in the absence of
fever should be evaluated for alternative diagnoses . Symptoms of cystitis may or
may not be present . In some cases, the presentation may mimic pelvic
inflammatory disease. Rarely, patients with acute pyelonephritis present with
sepsis, multiple organ system dysfunction, shock, and/or acute renal failure

1
B. OBJECTIVES OF THE STUDY

This study aims to further analyze a patient’s condition providing the

students of team 1 a definite idea on how it is to care for patient with the same
disease condition and how to interconnect all the other laboratory and significant
findings of the physician to associate to the patient’s current state condition.
Proper management and nursing interventions are also given priority to
emphasize the importance of nursing care to an ill patient. The study also has an
objective of assessing and assisting the patient from her present condition
towards the patient’s improvement in a higher level of wellness.

C. SCOPE OF LIMITATIONS

The study covers 2 days of assessment and care during our exposure at x
and rendered our care to the patient from Genearal ward station 2, these
includes thorough assessment, giving of nursing interventions, carrying out of the
doctor’s order, analyzing of the laboratory results relating the disease condition to
the anatomy and physiology of the human body the pathophysiology of the
disease.
The focus of the study is from the time when she was admitted in the
General ward x and Upon assessment, the patient and significant others was
very cooperative and responsive to all our questions.

2
VIII. Nursing System Review Chart
Name: x
BP: 100/80mmHg T: 35.3˚ C PR: 103 bpm RR: 24cpm
Weight: 45 kg Height: 5’2

EENT: hair loss

[ ] Impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion teeth
[ ] assess eyes ears nose
[ ] throat for abnormality [x ] no problem

RESPIRATORY pain
[ ] Asymmetric [ ] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [ x ] cough
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotics
[ ] assess resp. rate, rhythm, pulse blood
[ ] breath sounds, comfort [ ] no problem pitting edema

CARDIOVASCULAR: sunburn (dry)

[ ] arrhythmia [ x ] tachycardia [ ]numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[ ] no problem

GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain back pain
[ ] assess abdomen, bowel habits, swallowing
[ ] bowel sounds, comfort [ x ] no problem poor skin turgor

GENITO – URINARY AND GYNE

[ x ] pain [ ] urine color [ ] vaginal bleedin
[ ] hematuria [ ] discharge [ ] nucturia
[ ] assess urine frequency, control, color, odor, comfort
[ ] gyne bleeding [ ] discharge [ ] no problem
Weak
NEURO:
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors
[ x ] confused [ ] vision [ ] grip
[ ] assess motor, function, sensation, LOC, strength
[ ] grip, gait, coordination, speech [ ] no problem

MUSCULOSKELETAL and SKIN:

[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ x ] poor turgor [ ] cool [ x ] flushed
[ ] atrophy [ x ] pain [ ] ecchymosis [ ] diaphoretic moist
[ ] assess mobility, motion gait, alignment, joint function
[ ] skin color, texture, turgor, integrity [ ] no problem

3
V. Medical Management

a. Laboratories

Date: August 02, 2009

Examination desired: AFB No. 3
Specimen: Sputum (negative)
Rationale:
For Acid Fast Bacilli test

Date: July 29, 2009

Examination desired: Complete Blood Count
Specimen: Blood

Rationale:
A complete blood count (CBC) test measures the following:

• The number of red blood cells (RBCs)

• The number of white blood cells (WBCs)
• The total amount of hemoglobin in the blood
• The fraction of the blood composed of red blood cells (hematocrit)
• The mean corpuscular volume (MCV) -- the size of the red blood cells

CBC also includes information about the red blood cells that is calculated from
the other measurements:

• MCH (mean corpuscular hemoglobin)

• MCHC (mean corpuscular hemoglobin concentration)

4
The platelet count is also usually included in the CBC.
Result Normal Range Remarks

White cell count 13.54 3.5-10.8 x10^g/L infection

RBC 2.74 3.9-5.2 x10^g/L
Hgb 73 120-160g/dl anemia
Hct 0.22 .37-.45% anemia
Mch 25 27-33 g/dL
MCHC 31 32-36 g/dL
Lymphocytes 0.02 .20-.45% exhausted immune system
Neutrophils 0.95 .48-.73%

Date: July 23, 2009

Examination desired: U/A
Specimen: Urine

Rationale:
Urinalysis is the physical, chemical, and microscopic examination of urine.
It involves a number of tests to detect and measure various compounds that pass
through the urine.
Color : yellow
Transparency: clear
Sp. Gravity : 1.010
Ph : 7.0
Protein : trace
Microscopic Findingss
RBC : 4-6/hpf

5
WBC : 7-9/hpf
Epithelial cells: few
Renal cells: few
Triple phosphate: few

Date: July 23, 2009

Examination Desired: Fecalysis
Specimen: Stool

Color and Character: brown

Consistency: soft
Amoeba: negative
Intestinal parasitic: negative

Date: July 29, 2009

Examination Desired: Blood Chemistry
Specimen: Blood

Creatinine: 3.5 0.8-1.5 mg/dL

Sodium: 120.4 135-155 mmol/L
Potassium 5.24 3.5-5.5 mmol/L

Date: July 27, 2009

Examination Desired: (HGT) hemoglucotest
Specimen: Blood

Hgt = 134.0 mg/dL 80-120 mg/dL

6
 Date: July 29, 2009
Examination desired: Chest x-ray

Rationale: The chest x-ray is performed to evaluate the lungs, heart and chest
wall.

A chest x-ray is typically the first imaging test used to help diagnose symptoms
such as:

• flank pain

Impression:
Pneumonia left
Cannot rule out PTB
Atheromatous Aorta

B. Medical Orders With Rationale

DOCTOR'S ORDER
July 29, 2009

 Please admit to room of choice under  To provide care and close monitoring.
the supervision of Dr. Ladlad Sabal
 Secure consent to care  Consent is essential for any treatment;
routine procedures are covered by a
consent signed at admission.
 TPR q 4  Provide a baseline data for care. During
this period of time,
complications( hypotension,shock,
pulmonary edema) may possibly
develop.
 DAT  Diet as tolerated to maintain nutritional
status of patient
 Start IVF with PNSS 1L @ 30ggts/min
• To maintain fluid and electrolyte balance

7
 Laboratories
 To check lung status since the mother
 Chest X-Ray complained that her baby experienced
shortness of breath.

 Routine laboratory test upon admission

 Hematology and to assess infection-anemia and or
bleeding problem.
 To screen patient's urine for renal/
 Urinalysis urinary detect substances

• To check any abnormalities of the stool

 Fecalysis
• To monitor the sugar of the pt.
• Hgt
 Able to know any abnormalities from the
• Blood Chemistry blood.

• ECG 12 leads • To evaluate the functionality of the heart

• To assess pt. from head to toe
• Physical Assessment

Medications

• Omeprazole 40g IVTT now

• Gastrointestinal Agent
• Ranitidine 500mg 1tab q 4hrs. refer °C
> 37.8°C • Antiulcer Agent
• Cefuroxime 750mg IVTT q 8hrs.
( - ) ANST • Antibiotic Agent

• Ponstan 1cap TID

• I and O q shift • Nonsteroidal Anti-Inflammatory Drugs
• Labs to follow-up
• Pls. give Plasil 1amp. IVTT now then q
8hrs PRN for vomiting • Antiemetics Agent
• Thank You

8
 JULY 30 ,2009

• Maalox 10cc TID

• Cevox 500mg OD • Antacid Agent
• For AFB
• Increase IVF rate to 30-40 gtts/min
• Inability to sleep 11:45pm pls give
Iterax 25mg 1tab now
• 12mn IVF to follow with PNSS 1L @ • Anxiolytics Drugs
SR

JULY 31 ,2009

• For sputum smear

• 11:10pm PNSS @ SR

August 01 ,2009

• IVF to follow PNSS 1L @ SR

• D/C Cevox, Cefuroxime, Ceptrin
• 7am IVF to follow PNSS 2L @ SR

August 02,2009

• Ranitidine 150mg BID

• 11:10am may give Tritab 1tab TID if not
tolerated 3tabs
• May have soft diet
• 11pm IVF to follow in PNSS 1L @ SR

9
10
 Name of Date Classification Dose/ Mechanism Specific Contraindicatio Side Nursing
drugs Ordered Frequency of action Indication n Effects Precautio
/ Route n
.
Ranitidine July 29, Antiulcer 750mg Competitivel For Contraindicated Vertigo Assess
2009 every 8 y inhibits gastric in patients Malaise patient for
hours action of ulcer hypersensitive Headache abdominal
IVTT histamine H2 to drug and Blurred pain note
on the H2 at blocker those with vision presence
receptor acute Jaundice of blood in
sites of porphyria. emesis,
parietal stool, or
cells, gastric
decreasing aspirate.
gastric acid Instruct
secretion. patient to
take
without
regard to
meals
because
absorption
isn’t
affected
by food.

.
Cefuroxim July 29, Antibiotic 750mg Bactericidal: Treatmen - Hyper- Head- Do not
e 2009 IVTT every Inhibits t of sensitive to ache,dizzi mix w/ IV
8 hours synthesis of infection drug ness, solutions

11
 bacterial cell in the rash, containing
wall,causing urinary weakness, aminoglyc
cell death. tract. nausea, osides
vomiting,p
ain

Omeprazo July 29, Gastrointestin 40g IVTT An anti- Duodenal Long term use Headache Monitor
le 2009 al agent; now secretory and for duodenal , urinalysis
Proton pump compound gastric ulcers and dizziness, for
inhibitor that is acid ulcer. lactation. fatigue, hematuria
pump diarrhea, and
inhibitor. abdominal proteinuri
Suppresses pain a.
gastric acid
secretion.

Ponstan July 29, Nonsteroidal 1 cap TID a To relieve Patients who Diarrhea, should be
2009 Anti- nonsteroidal pain. have exhibited nausea discontinu
inflammatory agent with hypersensitivity and ed if
Drugs demonstrate to Ponstan. vomiting, rashes
(NSAIDs) d anti- Because the abdominal occur.
inflammator potential exists pain
y, analgesic for cross-
and sensitivity to
antipyretic aspirin or other
activity in nonsteroidal
laboratory anti-
animals. It is inflammatory

12
 not a drugs, ponstan
narcotic. should not be
Ponstan given to
was found patients in
to inhibit whom these
prostaglandi drugs induce
n synthesis symptoms of
and to bronchospasm,
compete for allergic rhinitis
binding at or urticaria.
the
prostaglandi
n receptor
sites in
animal
models.

Plasil July 29, Antiemetics 1amp. stimulates Disturban headache,

2009 IVTT now motility of ces of Hypersensitivity dizziness, Plasil
then q the upper gastrointe to plasil. nausea, ampules
8hrs. PRN gastrointesti stinal galactorrh contain
for nal tract motility, ea, sodium
vomiting without including gynecoma metabisulf
stimulating gastroeso stia, rash ite which
gastric, phageal including may
biliary or reflux and urticaria, cause
pancreatic diabetic or bowel allergic-
secretions. gastropar disturbanc type
Its mode of esis es may reactions,
action is (diabetic occur. including

13
unclear. It gastric anaphylac
seems to stasis). tic
sensitize Nausea symptoms
tissues to and and life-
the action of vomiting threatenin
acetylcholin of central g or less
e. The effect and severe
of peripheral asthmatic
metoclopra origin episodes
mide on associate in certain
motility is d with susceptibl
not surgery, e people.
dependent metabolic The
on intact diseases, overall
vagal infectious prevalenc
innervation diseases, e of sulfite
but it can be migraine sensitivity
abolished by headache in the
anticholiner , or drugs general
gic drugs. including population
cancer is
chemothe unknown
rapy. To and
facilitate probably
small low.
bowel Sulfite
intubation sensitivity
and is seen
radiologic more
al frequently
procedur in

14
 es of asthmatic
gastrointe than in
stinal non-
tract. asthmatic
Maalox July 30, Antacid 10cc TID Gastrointe people.
2009 Symptom Use in severely stinal side
atic relief debilitated effects are
Maalox is a of patients or in uncommo
balanced hyperacid those suffering n.
mixture of 2 ity and as from kidney Care
antacids: antiflatule failure. Occasiona should be
Aluminum nt to lly, high observed
hydroxide is alleviate doses of if used by
a slow- symptom antacids diabetics
acting s of gas, may because
antacid and including cause of the
magnesium post- diarrhea sugar
hydroxide is operation or content in
fast acting. gas pain. constipatio the tablet.
The 2 are n. The
frequently prolonged
combined in use of
antacid antacids
mixtures. in patients
Aluminum with renal
hydroxide failure
on its own is should be
astringent avoided.
and may
cause
constipation.

15
 This effect is
balanced by
the effect of
magnesium
hydroxide,
which, in
common
with other
Iterax July 30, Antihistamine 25mg 1tab magnesium
2009 s& now salts, may Patients who
Antiallergics, cause Symptom have shown a
Anxiolytics diarrhea. atic previous Drowsines
treatment hypersensitivity s, dry
Iterax is of to hydroxyzine. mouth, Administe
unrelated anxiety. Intermittent tremor red
chemically Generaliz acute and concomita
to the ed porphyria. convulsion ntly with
phenothiazi anxiety hydroxyzi
nes, disorder ne, their
reserpine, (GAD). dosage
meprobamat As should be
e or the premedic reduced.
benzodiaze ation to
pines. It is general
not a anesthesi
cortical a.
depressant, Symptom
but its action atic
may be due treatment
to a of pruritus
suppression of allergic

16
 of activity in origin.
certain key
regions of
the
subcortical
area of the
central
nervous
system.
Tritab August Anti-TB 1tab TID if Primary
02, 2009 agents not skeletal
tolerated muscle Patients with
3tabs relaxation severe hepatic Fever,
has been damage and chills,
demonstrate acute gout. malaise, Closely
d For the nausea monitor
experimenta maintena and patients
lly. nce vomititng on
phase intermitten
suppresses treatment t therapy
bacterial of all for
RNA forms of complianc
synthesis by pulmonar e and
binding to y and caution
the β- extrapulm them
subunit of onary against
DNA- tuberculo intentional
dependent sis. or
RNA accidental
polymerase, interruptio
thus n of

17
inhibiting the prescribed
attachment therapy
of the because
enzyme to of
DNA, increased
blocking risk of
RNA serious
transcription adverse
and reactions.
elongation.
It does not
inhibit the
counterpart
mammalian
enzyme.

18
XIII. HEALTH TEACHINGS

Medication ~ The patient was instructed to take the home medications

as prescribed by his attending physician.
~ Patient and significant others was instructed about the
proper administration of medications according to right
dose, right time, right route, and be cautions to possible
side effects.
Exercise ~ We instructed the patient to void properly.
~ We instructed the patient for early ambulation.
Treatment Instructed pt. to increase fluid intake 2L/day for fluid
replacement.
Encouraged pt. for adequate bed rest to let the pt. rest.
Instructed pt. to take daily vitamins especially vitamin C for
the immune system.
Out-Patient The patient was advised to have a follow-up check up at
(Check-up) Out Patient Department, 1 week after discharge for further
medication if needed and also to re-evaluate the patient’s
condition if it is progressing.
Diet Patient’s was instructed to eat nutritious food such as the
Grow, Glow, and Go groups of foods. Example green leafy
leaves vegetables such as malunggay. Kangkong,
camotetops, and ect.
And avoid salty foods such as ginamos, uyap, and dried
fish.
Instructed to increased fluid intake for fluid replacement.\

REFFERALS:
 We as a students nurse were able to meet some of our objectives and
some nursing interventions applied to our patient because we only have limited
time to deal with our patient’s condition.
Refferals are necessary for patient Mrs. A. to be able to promote healing
and recovery. This will facilitate for a better health status physically, emotionally,
mentally, and spiritually. For patient Mrs. A., recommendations would include but
not limited to the following: First, Mrs. A. should be able to develop an optimistic
attitude towards situations in order to promote positive inclination of mental and
emotional dimension of health. Second, she should strictly comply with the
medication regimen since personal adherence is a determinant of willingness
and eagerness to recover. Third, she should also be able to verbalize her
feelings especially regarding pain to prompt the support persons to take
emotional care and actions. This is essential when associated with health
seeking behavior. She should be able to express any discomfort in order for the
health care provider to carry out certain measures. In certain instances, when
these feelings are kept unobserved and unnoticed lead to development of a more
serious condition or possibly complications moreover, immediate medical
treatment should be pursued when there are manifestations or signs and
symptoms of an undergoing condition. Patient Mrs. A. should be able to establish
direct open communication with her family and health practitioners to link care
and needs. Patient Mrs. A. support persons can prove functional when they are
able to provide comfort and care measures, comfort include being available for
the patient. They encourage the patient to follow health care provider’s
instructions particularly medication adherence. In taking care of the patient,
taking turns or relieving can be used in order to cater the patient’s personal
needs of care and attention. All these actions can be initiated by the support
persons in order to promote emotional and mental support to patient Mrs. A.

20
EVALUATION

At the end of 2 days of assessment we had been able to establish rapport and
trust towards the patient and also to the significant others. We had been able to
determine possible problems that compromise the health of the patient, fortunate
nursing care intervention was developed the physical, mental and emotional well
being of the patient.
We implemented the planed interrelationship and evaluate our actions for
the benefit of our patient. We had been able to render nursing care services and
impart health teachings related to the health conditions of our patient.

XVII. BIBLIOGRAPHY

Books:
1.) Manual of Nursing Practice 7th edition by Lippincott.
2.) Nurses Pocket Guide 9th edition by Moorhouse
3.) Basic Pathology, 6th ed. Kumar, V., Cotran, R., Robbins, S.L. W.B. Saunders,
1997, page 456.
4.) Medical Surgical Nursing by Lippincott.

Web Sites:
www.yahoo.com
www.kidshealth.com

21
TABLE OF CONTENTS

I. INTRODUCTION
II. PROFILE OF THE PATIENT
III. DEVELOPMENTAL THEORY
IV. HEALTH HSTORY
a.) Personal Health History
b.) History of Present Illness
V. MEDICAL MANAGEMENT
a.) Laboratory Results
b.) Medical Orders With Rationale
c.) Drug Study
VI. ANATOMY AND PHYSIOLOGY
VII. PATHOPHYSIOLOGY
VIII.NURSING ASSESSMENT
a.) Nursing System Review Chart
IX. NURSING MANAGEMENT
a.) Ideal Nursing Management
b.) Actual Nursing Management
X. EVALUATION AND IMPLICATION
XI. REFERRALS AND FOLLOW-UP
XII. BIBLIOGRAPHY

22
VI. ANATOMY AND PHYSIOLOGY

23
Urinary System
Pee is one of the first body fluids a kid learns about. You probably learned
about pee (also called urine) when you were 2 or so, when you started using the
toilet instead of diapers. Now that you're older, you can understand much more
about the amazing yellow stuff called pee.
Parts of the Urinary Tract
You drink, you pee. But urine is more than just that drink you had a few hours
ago. The body produces pee as a way to get rid of waste and extra water that it
doesn't need. Before leaving your body, urine travels through the urinary tract.
The urinary tract is a pathway that includes the:
 Kidneys: two bean-shaped organs that filter waste from the blood and
produce urine
 ureters: two thin tubes that take pee from the kidney to the bladder
 Bladder: a sac that holds pee until it's time to go to the bathroom
 Urethra: the tube that carries urine from the bladder out of the body when
you pee
The kidneys are key players in the urinary tract. They do two important jobs —
filter waste from the blood and produce pee to get rid of it. If they didn't do this,
toxins (bad stuff) would quickly build up in your body and make you sick. That's
why you hear about people getting kidney transplants sometimes. You need at
least one working kidney to be healthy.
You might wonder how your body ends up with waste it needs to get rid of. Body
processes such as digestion and metabolism (when the body turns food into
energy) produce wastes, or byproducts. The body takes what it needs, but the
waste has to go somewhere. Thanks to the kidneys and pee, it has a way to get
out.
When you're asked to give a urine sample during a doctor's visit, the results
reveal how well your two kidneys are working. For example, white blood cells in
the urine can be a sign of an infection.
Pee also is a way for your body to keep the right amount of water. Did you ever
notice that if you drink a lot, you pee more and the pee is pale yellow? That's

24
because your body is getting rid of extra water and your pee has more water in it
than other stuff.
What's Pee Made Of?
Let's talk more about how the kidneys filter blood. When blood goes through the
kidneys, water and some of the other stuff that is in blood (like protein, glucose,
and other nutrients) go back into the bloodstream, while the excess stuff and
waste is taken out. Urine is what is left behind. But what is it exactly?
Urine contains:
 water
 urea, a waste product that forms when proteins are broken down
 urochrome, a pigmented blood product that gives urine its yellowish color
 salts
 creatinine, a waste product that forms with the normal breakdown of
muscle
 byproducts of bile from the liver
 ammonia
Once pee is produced, it travels from the kidney to the bladder, where it's stored
until you need to go to the bathroom. The bladder expands as it fills; when it's
full, nerve endings in the bladder wall send a message to the brain that you need
to pee.
When you're in the bathroom, ready to go, the bladder walls contract and the
sphincter (a ringlike muscle that guards the exit from the bladder to the urethra)
relaxes. The urine then flows from the bladder and out of the body through the
urethra. For boys, the urethra ends at the tip of the penis. For girls, it's above the
vaginal opening.

25
IX. Pathophysiology

Pyelonephritis is a common suppuratives inflammation of the kidney and

renal pelvis caused by bacterial infection. Pyelonephritis is usually associated
with an infection of lower urinary tract and occurs more frequently in females.
Bacteria infect the kidneys via the bloodstream and from the lower urinary tract.

Predisposing Factors: Precipitating Factors:

Age = 52y.o. Hygiene
UTI Urination Habit
Prolonged urination
Sexual contact
Gender = female
E.coli

Enteric Gran-negative rods, such as E. coli (most important), Proteus, Klebsiella,

Enterobacter, and Pseudomonas are the principal causative agents.

Bacteria that reach the pelvis infect the medulla and the collecting ducts, causing
tubular epithelial necrosis, hemorrhage, and stimulate an inflammatory response.

Placement of urinary catheters, pregnancy and diabetes increase the likelihood

of urinary tract infections.

Hematogenous infection is less common and results from seeding of the kidneys
due to septicemia or bacterial endocarditis.

26
Vesicoureteral reflux occurs more readily with an uretheral obstruction or cystitis
as the urinary bladder pressure is increased and the normal vesicoureteral valve
is compromised.

An ascending infection from the ureter is the most important route and results
from the reflux of bacterial-contaminated urine (vesicoureteral reflux) from the
lower urinary tract.

Signs and Symptoms Complications

• Fever - Chronic Pyelonephristis
• Nausea and vomiting
• Dysuria
• Abdominal pain
• Flank pain
• Warm to touch
• Flushed skin
• Fatigue

27
XI. IDEAL NURSING INTERVENTION
NURSING DIAGNOSIS: Deficient Fluid Volume related to hypermetabolic state
ACTIONS/INTERVENTIONS
Independent
Monitor intake and output (I&O), and correlate
with weight changes. Measure blood/fluid
losses via emesis, gastric suction/lavage, and
stools.
Keep accurate record of subtotals of
solutions/blood products during replacement
therapy.
Maintain bedrest; prevent vomiting and
straining at stool. Schedule activities to provide
undisturbed rest periods. Eliminate noxious
stimuli.
Elevate head of bed during antacid gavage.
Note signs of renewed bleeding after cessation
of initial bleeding.
Observe for secondary bleeding, e.g.,
nose/gums, oozing from puncture sites,
appearance of ecchymotic areas following
minimal trauma.
Provide clear/bland fluids when intake is
resumed. Avoid caffeinated and carbonated
beverages.
Collaborative
Administer IV fluids/volume expanders as
indicated, e.g., 0.9% sodium chloride, lactated
Ringer’s solution;
RATIONALE
Provides guidelines for fluid replacement.
Potential exists for overtransfusion of fluids,
especially when volume expanders are given
before blood transfusions.
Activity/vomiting increases intra-abdominal
pressure and can predispose to further
bleeding.
Prevents gastric reflux and aspiration of
antacids, which can cause serious pulmonary
complications.
Increased abdominal fullness/distension,
nausea or renewed vomiting, and bloody
diarrhea may indicate rebleeding.
Loss of/inadequate replacement of clotting
factors may precipitate development of DIC.
More easily digested and reduce risk of added
irritation to inflamed tissues. Caffeine and
carbonated beverages stimulate hydrochloric
acid (HCl) production, possibly potentiating
rebleeding.
Fluid replacement with isotonic crystalloid
solutions depends on degree of hypovolemia
and duration of bleeding (acute or chronic).
Other volume expanders, such as albumin,
may be infused until type and cross-matching
can be completed and blood transfusions
begun. Approximately 80%–90% of gastric
bleeding is controlled by fluid resuscitation and
medical management without transfusion of
blood products.
28
 NURSING DIAGNOSIS: Acute pain related to acute inflammation of renal tissues
ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Note reports of pain, including location,
duration, intensity (0–10 scale).
Review factors that aggravate or alleviate pain.
Note nonverbal pain cues, e.g., restlessness,
reluctance to move, abdominal guarding,
tachycardia, diaphoresis. Investigate
discrepancies between verbal and nonverbal
cues.
Provide small, frequent meals as indicated for
individual patient.
Identify and limit foods that create discomfort.
Assist with active/passive range of motion
(ROM) exercises.
Provide frequent oral care and comfort
measures, e.g., back rub, position change.
Collaborative
Provide and implement prescribed dietary
modifications.
RATIONALE
Pain is not always present, but if present
should be compared with patient’s previous
pain symptoms. This comparison may assist in
diagnosis of etiology of bleeding and
development of complications.
Helpful in establishing diagnosis and treatment
needs.
Nonverbal cues may be both physiological and
psychological and may be used in conjunction
with verbal cues to evaluate extent/severity of
the problem.
Food has an acid neutralizing effect and dilutes
the gastric contents. Small meals prevent
distension and the release of gastrin.
Specific foods that cause distress vary among
individuals. Studies indicate pepper is harmful,
and coffee (including decaffeinated) can
precipitate dyspepsia.
Reduces joint stiffness, minimizing
pain/discomfort.
Halitosis from stagnant oral secretions is
unappetizing and can aggravate nausea.
Gingivitis and dental problems may arise.
Patient may receive nothing by mouth (NPO)
initially. When oral intake is allowed, food
choices depend on the diagnosis and etiology
of the bleeding.
29
 NURSING DIAGNOSIS: Imbalance nutrition less than body requirements related to
ingest food as evidence by nausea and vomiting
ACTIONS/INTERVENTIONS
Independent
Assess/document dietary intake.
Provide frequent, small feedings.
Give patient/SO a list of permitted foods/fluids
and encourage involvement in menu choices.
Offer frequent mouth care/rinse with dilute
(0.25%) acetic acid solution; provide gum, hard
candy, breath mints between meals.
Weigh daily.
Collaborative
Monitor laboratory studies, e.g., BUN,
prealbumin/albumin, transferrin, sodium, and
potassium.
Consult with dietitian/nutritional support team.
RATIONALE
Aids in identifying deficiencies and dietary
needs. General physical condition, uremic
symptoms (e.g., nausea, anorexia, altered
taste), and multiple dietary restrictions affect
food intake.
Minimizes anorexia and nausea associated
with uremic state/diminished peristalsis.
Provides patient with a measure of control
within dietary restrictions. Food from home may
enhance appetite.
Mucous membranes may become dry and
cracked. Mouth care soothes, lubricates, and
helps freshen mouth taste, which is often
unpleasant because of uremia and restricted
oral intake. Rinsing with acetic acid helps
neutralize ammonia formed by conversion of
urea.
The fasting/catabolic patient normally loses
0.2–0.5 kg/day. Changes in excess of 0.5 kg
may reflect shifts in fluid balance.
Indicators of nutritional needs, restrictions, and
necessity for/effectiveness of therapy.
Determines individual calorie and nutrient
needs within the restrictions, and identifies
most effective route and product, e.g., oral
supplements, enteral or parenteral nutrition.
30
XII. ACTUAL NURSING INTERVENTION

S “Sakit akong tiyan og likod” as verbalized by the patient.

O ~ facial grimace
~ guarding at the abdominal area
~ vomits 3-4 times
A Acute pain related to acute inflammation of renal tissues
P Long term: at the end of 1-2hrs., the pt. will be able to report pain
is relieved.
Short term: at the end of 30 min. the pt. will be able to report pain
is controlled.
I 1. Backrub done
R: To provide nonpharmacological pain management.
2. Encouraged adequate rest periods.
R: To alleviate pain
3. Breathing technique 5 minutes.
R: To alleviate and control pain.
4. Provided quiet environment, calm activities.
R: To promote comfort.
5. administer analgesic
R: To relieved pain.
E At the end of the interventions the patient was able to report pain
is relieved.

S “ga-sukaha lage ko” as verbalized by the patient.

O ~ vomiting ~ weak

31
 ~ nausea ~ loose bowel movement
A Deficient fluid volume related to hypermetabolic state.
P Long term: at the end of 3-4hrs. the pt. will be able to back her
body fluid to normal volume.
Short term:at the end of 5-10min. the pt. will be able to stable her
condition.
I 1. We established fluid replacement needs by encouraging
fluid intake.
R: To replace fluid loss.
2. Maintained bed rest; prevent vomiting and straining at stool.
R: Activity/vomiting increases intra-abdominal pressure and
can predispose to further bleeding.
3. Provided oral care.
R: To prevent injury from dryness.
5. Monitored I and O
R: to ensure accurate picture of fluid status
6. Administered IVF PNSS 1L @ 30gtts/min.
R: For fluid and electrolytes replacement.
E At the end of 5-10 mins. the patient’s condition was stable.

S “Wala koy gana mokaon, kay kong mokaon ko ako raman gihapon
isuka” as verbalized by the patient.
O ~ Loss weight

32
 ~ inadequate food intake
~ weakness
~ vomiting
A Nutrition Imbalance less than body requirements related to
inability to ingest food as evidence by nausea and vomititng.
P Long term: At the end of the day the pt’s nutritional status will be
stable.
Short term: At the end of 8 hours the patient will be able to
regained appetite.
I 1. Promoted pleasant and relaxing environment.
R: To enhance food intake.
2. Promoted adequate/timely fluid intake.
R: (Limiting fluids 1 hour prior to meal decreases possibility of
early satiety).
3. Emphasized importance of well-balanced, nutritious intake.
R: To promote wellness.
4. Provided oral care.
R: To promote appetite.
5. Administered IVF PNSS 1L @ 30gtts/min.
R: Serves as parenteral supplement.
E At the end of 8 hours the patient was able to gained appetite.

33
 Liceo de Cagayan University
COLLEGE OF NURSING
R.N. Pelaez Avenue, Cagayan de Oro City

In Partial Fulfillment in
NCM501204-RLE

Submitted to:
x
Clinical Instructor

Submitted by:
x

RATING SCALE
A. WRITTEN WEIGHT RATING

1. Developmental Data
2. Health History & Present Illness

3. Medical Orders, Rationale

4. Pathophysiology

34
5. Ideal Nursing Management

6. Actual Nursing Management

7. Evaluation and Implication

8. Referrals and Follow-up

9. Organization and Grammar/Bibliography

Total Grade _____________

Equivalent x 60%
B. ORAL DEFENSE WEIGHT RATING
1. Content

- Master of Subject
- Knowledge and understanding of important points to be emphasized

- Organization of Plan
2. Presentation
- Creativity and Ingenuity
- Ability to hold interest and participation
- Ability to stimulate group participation
3. Delivery
- Diction and voice
- Pose and Grooming

4. responds to questions ( makes sound judgment and expresses oneself)

5. Attitude towards comments and suggestions

Total Grade
Equivalent x 40%

Final Grade

NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVE
COMMUNICATION :

hearing Loss Comments: “wala man glasses languages

visual Changes koy problema sa contract lens hearing aide
akong panlantaw speech difficulties
denied as verbalized by the pt. Pupil Size 3mm
Reaction: PERRLA
OXYGENATION :

dyspnea Comments:“dini naman Resp. regular irregular

ko gi Describe: pt’s respiratory is nit within normal
ubo pero gamay range. RR= 24cpm

35
raman” as
as verbalized by the pt. R: symmetric to the right lung
smoking history L symmetric to the left lung
cough

sputum

denied
CIRCULATION :
Chest pain Comments: “ dili man
sakit Heart Rhythm regular irregular
Nanghupong lang” as Ankle Edema: Noted at the left side of the feet
verba Pulse Car. Rad. DP
Lized by the pt. R + + 103 +
L + + 103 +
Leg pain Comments: pulses are palpable.
Numbness
Of extremities
Denied
NUTRITION :
Diet: Soft Diet
Dentures None
N V Comments:“wala koy
Character gana mokaon kai kada
Recent change kaon nako kasukaon FULL PARTIAL
In weight, appetite dayon ko” as verbalized Upper:
by Lower:
the pt.
Swallowing
difficulty
denied
ELIMINATION :
Usual bowel pattern urinary frequency
Once a day 3-4 times a day Comments: the pt’s bowel sounds was active
constipation urgency Abdominal
remedy dysuria Distention
none hematuria Present yes
Date of last BM incontinence no
Aug. 2/09 polyuria Urine color:yellow
Diarrhea foly in place Odor:aromatic
Character denied
None
MGT. OF HEALTH ILLNESS Briefly describe the patients abiltity to follow
Alcohol denied treatments for chronic health problems.
(amount , frequency)
SBE: Last Pap Smear unrecalled Patient was able to comply with his
LMP: unrecalled medications and treatment regimen as
prescribed by the physician

36
 SUBJECTIVE OBJECTIVE

SKIN INTEGRITY: Dry cold pale

Comments:”sunburn Flushed warm
ako Moist cyanotic
Dry panit kai nangalogo mi dagat
Itching ” as The patient was temperature was 35.2°
Verbalized by the
Other – patient

Denied

ACTIVITY/SAFETY: LOC and Orientation: patient is

Convulsion Comments: “limitado oriented to time and place
dizziness na lagi ni akong lihok
limited motion tungod ani akong paa ROM limitations: patient has limited
of joints maski pagkaligo ug motion because of the edma at left side of her
pag feet.
Limitation in pangihi ga alalayan
pako
Ability to as verbalIzed by the
pt”
Ambulate
Bathe self
denied

COMFORT/SLEEP/AWAKE: Facial Grimaces

Pain Comments: “ga lisod ko Guarding
tulog Other signs of pain :pain at her back
(location) sakit ako likod” porton
frequency
remedies) asverbalized
nocturia by the patient.”
sleep difficulties
denied

COPING: Observed non-verbal behavior: facial

Occupation: retired teacher grade 1
Members of Household: 4
Most supportive Person: daughter
grimace was observed and non
verbal behavior
The person and his phone number that can
be reached any time: Not given an
opportunity.

37
38