July 28, 2017 | Author: Amaizing Grace Mejia Carlos | Category: Kidney, Homeostasis, Organ (Anatomy), Genitourinary System, Animal Anatomy
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ACUTE PYELONEPHRITIS PRESENTED BY: GROUP C Balot, Jr,, German M. Bugarin, Rhadharani Paula Mae N. Buhat, Janny Lie R. Camangeg jr., Joselito M. Cambia, Charlene M. Canosa, Julie Ann U. Cansino, Rina Antonette P. Cairel, Princess C. Carabacan, Arleen C. Carlos, Amazing Grace M. Casayuran, Karen Ivy V. Leal, Joenna Joy I.

PRESENTED TO: Mr. Jesper Bayaua, RN Mrs. Mary Jane Gonzales, RN Ms. Theresa Bermusa, RN Ms. Pristine Gonzales, RN


I. Introduction A.

Case Description

II. Demographic Data Nursing History A. B. C.

b. c.

Present Health History Past Medical History Family History D. Pattern of Functioning a. Physiological Health Socio-cultural Health Spiritual Health

Gordon’s Functional Pattern A. B. C. D. E. F. G. H. I. J. K.

Health Perception Nutrition Pattern Sleep and Rest Activity and Exercise Elimination Pattern Self Perception Cognitive and Perception Pattern Role and Relationship Pattern Sexuality Pattern Coping of Stress Pattern Value and Belief Pattern

III. Course in the Ward IV. Physical Assessment V. Laboratory Result VI. Anatomy and Physiology VII. Pathophysiology VIII. Nursing Care Plan IX. Drug Study X. Discharge Planning XI. Reference


Pyelonephritis Definition Pyelonephritis is an infection of the kidney and the ureters, the ducts that carry urine away from the kidney. Alternative Names Urinary tract infection - complicated; Infection - kidney; Complicated urinary tract infection; Kidney infection Causes Pyelonephritis most often occurs as a result of urinary tract infection, particularly when there is occasional or persistent backflow of urine from the bladder into the ureters or an area called the kidney pelvis. See:Vesicoureteric reflux Pyelonephritis can be sudden (acute) or long-term (chronic). • Acute uncomplicated pyelonephritis is the sudden development of kidney inflammation. • Chronic pyelonephritis is a long-standing infection that does not go away.

Pyelonephritis occurs much less often than a bladder infection, although a history of such an infection increases your risk. You're also at increased risk for a kidney infection if you have any of the following conditions: Backflow of urine into the ureters or kidney pelvis Kidney stones Ostructive uropathy Renal papillary necrosis You are also more likely to get a kidney infection if you have a history of chronic or recurrent urinary tract infection, especially if the infection is caused by a particularly aggressive type of bacteria. Acute pyelonephritis can be severe in the elderly and in people who areimmunosuppressed (for example, those with cancer or AIDS). • • • •

Symptoms • • • • • • • • • • •

Back pain orflank pain Chills with shaking Severe abdominal pain (occurs occasionally) Fatigue Fever Higher than 102 degrees Fahrenheit Persists for more than 2 days General ill feeling Chills with shaking Mental changes or confusion* Skin changes

          

Flushed or reddened skin Moist skin (diaphoresis) Warm skin Urination problems Blood in the urine Cloudy or abnormal urine color Foul or strong urine odor Increased urinary frequency or urgency Need to urinate at night (nocturia) Painful urination Vomiting, nausea

* Mental changes or confusion may be the only signs of a urinary tract infection in the elderly. Exams and Tests A physical exam may show tenderness when the health care provider presses (palpates) the area of the kidney. • Blood culture may show an infection. • Urinalysis commonly reveals white or red blood cells in the urine. • Other urine tests may show bacteria in the urine. An intravenous pyelogram (IVP) or CT scan of the abdomen may show swollen kidneys. These tests can also help rule out underlying disorders. Additional tests and procedures that may be done include: • • • •

Kidney biopsy Kidney scan Kidney ultrasound Voiding cystourethrogram

Treatment The goals of treatment are to: • •

Control the infection Relieve symptoms

Due to the high death rate in the elderly population and the risk of complications, prompt treatment is recommended. Sudden (acute) symptoms usually go away within 48 to 72 hours after appropriate treatment. Your doctor will select the appropriate antibiotics after a urine culture identifies the bacteria that is causing the infection. In acute cases, you may receive a 10- to 14-day course of antibiotics. If you have a severe infection or cannot take antibiotics by mouth, you may be given antibiotics through a vein (intravenously) at first. Chronic pyelonephritis may require long-term antibiotic therapy. It is very important that you finish all the medicine. Commonly used antibiotics include the following: • • •

Amoxicillin Cephalosporin Levofloxacin and ciprofloxacin

Sulfa drugs such as sulfisoxazole/trimethoprim

Outlook (Prognosis) With treatment, most kidney infections get better without complications. However, the treatment may need to be aggressive or prolonged. Pregnant women and persons with diabetes or spinal paralysis should have a urine culture after finishing antibiotic therapy to make sure that the bacteria are no longer present in the urine. In rare cases, permanent kidney damage can result when: Chronic kidney infections occur in a transplanted kidney Many kidney infections occur during infancy or childhood Acute kidney injury (acute renal failure) may occur if a severe infection leads to significantly low blood pressure (shock). The elderly, infants, and persons with a weakened immune system have an increased risk for developing shock and a severe blood infection calledsepsis. Often, such patients will be admitted to the hospital for frequent monitoring and IV antibiotics, IV fluids, and other medications as necessary. • •

Severe episodes of acute kidney injury may result in permanent kidney damage and lead to chronic kidney disease. Possible Complications • • • •

Acute kidney failure Kidney infection returns Infection around the kidney (perinephric abscess) Severe blood infection (sepsis)

When to Contact a Medical Professional Call your health care provider if you have symptoms of pyelonephritis. Call your health care provider if you have been diagnosed with this condition and new symptoms develop, especially: • • •

Decreased urine output Persistent high fever Severe flank pain or back pain

Prevention Prompt and complete treatment of bladder infections may prevent development of many cases of pyelonephritis. Chronic or recurrent urinary tract infection should be treated thoroughly. You can help preventing kidney infections by taking the following steps: • Keep the genital area clean. Wiping from front to back helps reduce the chance of introducing bacteria from the rectal area to the urethra. • Urinating immediately after sexual intercourse. This may help eliminate any bacteria that may have been introduced during sexual activity. • Drink more fluids (64 to 128 ounces per day). This encourages frequent urination and flushes bacteria from the bladder. • Drink cranberry juice. Doing so prevents certain types of bacteria from attaching to the wall of the bladder and may lessen your chance of infection.



pt. She Lui


Plaridel Santiago City


25 years old


September 5, 1985







Civil Status:



Self Employed

Date of Admission:

August 23, 2010

Time of Admission: 10:03 am Attending Physician: Dr. Alex Cristobal Chief Complain:

Painful urination, fever with chills, vomiting for 2 days and body malaise

Admitting Diagnosis: t/c UTI Final diagnosis:

Initial Vital Signs: BP:








Acute Pyelonephritis

Nursing History

History of Present Illness 2days PTA, the patient was suffering from fever and chills accompanied by vomiting for seven times. She decided to have prompt consultation when she experience body malaise. She was rushed at Callang General Hospital and Medical Center last August 23, 2010 at 10:30 am accompanied by her father via ambulatory. Initial Vital is taken.BP—110/80 RR—21 PR--81 TEMP --38⁰

History of Present Illness According to the patient she has been hospitalized 6 years ago due to sensitivity of her pregnancy. She also suffers usual sickness like cough and colds. She often treated it with OTC drugs such as paracetamol and decongestant.

Family History The patient has a family history of Hypertension on Mother side and asthma to her Father side.

Gordon’s Functional Pattern Health Perception Pattern According to the pt she is not aware with her health status. She admits that she had already UTI before but she just ignore. For her health is very important but then as long as she can tolerate her illness she doesn’t even take medicines at all. Nutritional-Metabolic Pattern PTA, according to the patient she loves to chicken joy and fries (Jollibee) and eat only small amount of vegetables. During snack time her favorite snack is chippy and soft drinks for at least 2 liters a day. She only consumes 4 glasses of water a day. During hospitalization the pt is NPO as ordered due to her vomiting. Activity/Exercise Pattern PTA, according to the patient she had a efficient energy to require for her ADL. Every day she is in their store selling clothes for the whole day. During hospitalization, can no longer do her usual habit, but she can still perform her ADL. Coping Pattern According to the patient she is financially problematic because she is applying to abroad. She doesn’t have enough money especially now. That she was been Hospitalized. She managed her problems by asking help to her parents and through the support of her husband. Elimination Pattern PTA, the patient usually voids 5-7 times a day and defecates once a day. During the hospitalization the patient voids 10-12 times a day but scanty. She defecates every other day. Sleep Rest Pattern PTA, the patient sleep 7-8 hours a day. She sleep at 9:00 o’clock and wakes up 5:00 o’clock in the morning. During Hospitalization the patient didn’t sleep well. Her sleep was always interrupted because of giving medication and getting vital signs. Role Relationship Pattern PTA, the patient lives together with her family. She is responsible in doing the Household chores and caring for her daughter. During hospitalization she can no longer perform her responsibilities at home. Values Beliefs Pattern The patient is a member of Iglesia ni Cristo, They usually attend church gathering every Sunday. The family also believes in faith healer” Sexuality Pattern

According to the patient she had her 1st menstruation when she was 14 years old. She has a regular menstruation. They use natural method (withdrawal)for family planning and to prevent possible pregnancy.

Physical Assessment

August 23, 2010 (Monday, 6:00pm) Received patient, lying on bed, conscious and coherent, febrile, with an ongoing IVF of D5 .9 NaCl @ 21gtts/min, and initial v/s of BP: 90/60 mmHg, RR: 21 cpm, PR: 87 bpm, & Temp: 38 ˚C. BODY PARTS HEAD Hair





Black in color


Scalp FACE *EYES Eyebrows





Symmetrically aligned




Intact & equally distributed








Reddish to pinkish in color




White in color
















Dry, reddish in color

Due to diet (NPO) Due to fever



Pinkish in color




Complete, no dentures


Tongue NECK

Inspection Inspection

Pinkish,(-)lesions Symmetrical in both sides

Normal Normal




No tenderness & mass nodes Not distended


(+) bowel sound



(-) dull sound



(-) mass (-) tenderness









Capillary refill 2-3





*L arm


sec. Inspection

(-)bipedal edema



Inspection Inspection

Short & clean nails Warm to touch

Normal Due to fever


Progress note

Doctors order



BP: 110/80 Temp. 36.9 C ̊

 Admit to ROC

 For clients preference

 Secure consent

 For legal document and to start treatment and management

 For CBC

 To rule out blood components abnormalities

 For U/A

 To check if there is abnormalities.

 D5.09 NaCl 1L x 12̊

 Replacement of fluid and electrolytes imbalances  For fever

 Paracetamol 1 amp IV q 8̊  Ranitidine 1 amp IV now then q

8 for vomiting  v/s q 4

 To check any fluctuations.

 please inform AP

 To update prognosis to the pt.

 refer accordingly

3:00 pm


 To communicate any untoward signs and symptoms that may occur.

 NPO temporary

 To prevent recurrent vomiting.

 Ranitidine 50mg IV q 8

 H2 blocker antagonist to prevent or reduce N/V

 Cefuroxime 750mg IV q 8 (-) ANST


 H2 blocker antagonist to prevent or reduce N/V

 Antibiotic to treat bacterial infection

 IVF d5LR 1L x 8

 Replacement of fluid and electrolytes imbalances and for medication.

 May have DAT

 To sustain metabolic needs.

 Shift IV ranitidine to oral150mg

 H2 blocker antagonist to

 Continue Cefuroxime IV

 Antibiotic to treat bacterial infection

 IVF to follow D5LR 1L x 12̊

 Replacement of fluid and electrolytes imbalances and for medication.

T: 38 C ̊ BP: 90/60

prevent or reduce N/ Antibiotic to treat bacterial infection

 PLR 1L x 12̊

 Replacement of fluid and electrolytes imbalances and for medication.

 For repeat U/A

 For comparison

 I will be out of town, Dr. Butuyan will take over please inform.

 For specialized treatment and further management

 Give last dose of Cefuroxime @ 4pm tomorrow

 Antibiotic to treat bacterial infection


 Home meds. 1. Zinnat 5oomg BID x 5 days

 Antibiotic to treat bacterial infection

2. Paracetmol q 4̊

 Non Opiod analgesics and anti pyretic.







15.49 (10 ̂ g/L) 5.00 (10 ̂ 12/L) 112 (g/L) 32.8 % 65.3 (PL) 22.3 (Pg) 341 (g/L) 278 (10 ̂ g/L) 31.1 – 34.1 Fl 14.5 % 11.5 % 9.7 (fl) 23.1 % 0.27 % 14.04 % 0.75 % 0.68 (10 ̂ g/L) 0.01 (10 ̂ g/L) 0.01 (10 ̂ g/L)

5.00 – 10.00 4.00 – 5.00 110 – 180 27.0 – 54.0 86.0 – 110 26.0 – 38.0 310 – 370 150 – 400 37.0 – 54.0 11.0 – 16.0 9.0 – 17.0 9.0 – 13.0 13.0 – 43.0 0.17 – 0.35 1.50 – 7.00 1.00 – 3.70 0.00 – 0.70 0.00 – 0.40 0.00 – 0.10

d/t infection Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal


Color Transparency pH Specific Protein Glucose RBC

Dark yellow Turbid 6.5 pH 1.010 (normal = 1.010-1.025) (+) 30 mg/dl (-) 5 – 10

Pus cells Epithelial cells Amorphous materials Mucus threads Bacteria

100 numerous to count/ hpF Moderate Occasional Rare Occasional

INTERPRETATION d/t infection d/t infection normal normal d/t damage of the kidney normal d/t damage of the function of the kidney d/t infection normal normal normal normal





Transparency pH Specific Protein Glucose RBC

Slightly Turbid 7.0 pH 1.015 (normal = 1.010-1.025) (-) (-) 0-2

Pus cells Epithelial cells Amorphous materials Mucus threads Bacteria

30 – 40 HPF Moderate Occasional Rare Occasional

normal normal normal normal normal d/t damage of the function of the kidney d/t infection normal normal normal normal


The kidneys are essentially regulatory organs which maintain the volume and composition of body fluid by filtration of the blood and selective reabsorption or secretion of filtered solutes. The kidneys are retroperitoneal organs (ie located behind the peritoneum) situated on the posterior wall of the abdomen on each side of the vertebral column, at about the level of the twelfth rib. The left kidney is slightly higher in the abdomen than the right, due to the presence of the liver pushing the right kidney down. The kidneys take their blood supply directly from the aorta via the renal arteries; blood is returned to the inferior vena cava via the renal veins. Urine (the filtered product containing waste materials and water) excreted from the kidneys passes down the fibromuscular ureters and

collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending to accept urine without increasing the pressure inside; this means that large volumes can be collected (700-1000ml) without high-pressure damage to the renal system occuring. When urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts, and urine is voided via the urethra.

Structure of the kidney On sectioning, the kidney has a pale outer region- the cortex- and a darker inner region- the medulla.The medulla is divided into 8-18 conical regions, called the renal pyramids; the base of each pyramid starts at the corticomedullary border, and the apex ends in the renal papilla which merges to form the renal pelvis and then on to form the ureter. In humans, the renal pelvis is divided into two or three spaces -the major calyceswhich in turn divide into further minor calyces. The walls of the calyces, pelvis and ureters are lined with smooth muscle that can contract to force urine towards the bladder by peristalisis. The cortex and the medulla are made up of nephrons; these are the functional units of the kidney, and each kidney contains about 1.3 million of them. The nephron is the unit of the kidney responsible for ultrafiltration of the blood and reabsorption or excretion of products in the subsequent filtrate. Each nephron is made up of: A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as blood is filtered through this sieve-like structure. This filtration is uncontrolled. • The proximal convoluted tubule. Controlled absorption of glucose, sodium, and other solutes goes on in this region. • The loop of Henle. This region is responsible for concentration and dilution of urine by utilising a counter-current multiplying mechanism- basically, it is water-impermeable but can pump sodium out, which in turn affects the osmolarity of the surrounding tissues and will affect the subsequent movement of water in or out of the water-permeable collecting duct. • The distal convoluted tubule. This region is responsible, along with the collecting duct that it joins, for absorbing water back into the body- simple maths will tell you that the kidney doesn't produce 125ml of urine every minute. 99% of the water is normally reabsorbed, leaving highly concentrated urine to flow into the collecting duct and then into the renal pelvis. •

Blood supply The kidneys receive blood from the renal arteries, left and right, which branch directly from the abdominal aorta. Despite their relatively small size, the kidneys receive approximately 20% of the cardiac output. Each renal artery branches into segmental arteries, dividing further into interlobar arteries which penetrate the renal capsule and extend through the renal columns between the renal pyramids. The interlobar arteries then supply blood to the arcuate arteries that run through the boundary of the cortex and the medulla. Each arcuate artery supplies several interlobular arteries that feed into the afferent arterioles that supply the glomeruli.

The interstitum (or interstitium) is the functional space in the kidney beneath the individual filters (glomeruli) which are rich in blood vessels. The interstitum absorbs fluid recovered from urine. Various conditions can lead to scarring and congestion of this area, which can cause kidney dysfunction and failure. After filtration occurs the blood moves through a small network of venules that converge into interlobular veins. As with the arteriole distribution the veins follow the same pattern, the interlobular provide blood to the arcuate veins then back to the interlobar veins which come to form the renal vein exiting the kidney for transfusion for blood. Histology Renal histology studies the structure of the kidney as viewed under a microscope. Various distinct cell types occur in the kidney, including: • Kidney glomerulus parietal cell • Kidney glomerulus podocyte • Kidney proximal tubule brush border cell • Loop of Henle thin segment cell • Thick ascending limb cell • Kidney distal tubule cell • Kidney collecting duct cell • Interstitial kidney cell

Innervation The kidney and nervous system communicate via the renal plexus, whose fibers course along the renal arteries to reach the kidney. Input from the sympathetic nervous system triggers vasoconstriction in the kidney, thereby reducing renal blood flow. The kidney is not thought to receive input from the parasympathetic nervous system. Sensory input from the kidney travels to the T10-11 levels of the spinal cord and is sensed in the corresponding dermatome. Thus, pain in the flank region may be referred from the kidney.

Functions The kidney participates in whole-body homeostasis, regulating acid-base balance, electrolyte concentrations, extracellular fluid volume, and regulation of blood pressure. The kidney accomplishes these homeostatic functions both independently and in concert with other organs, particularly those of the endocrine system. Various endocrine hormones coordinate these endocrine functions; these include renin, angiotensin II, aldosterone, antidiuretic hormone, and atrial natriuretic peptide, among others. Many of the kidney's functions are accomplished by relatively simple mechanisms of filtration, reabsorption, and secretion, which take place in the nephron. Filtration, which takes place at the renal corpuscle, is the process by which cells and large proteins are filtered from the blood to make an ultrafiltrate that will eventually become urine. The kidney generates 180 liters of filtrate a day, while reabsorbing a large percentage, allowing for only the generation of approximately 2 liters of urine. Reabsorption is the transport of molecules from this ultrafiltrate and into the blood. Secretion is the reverse process, in which molecules are transported in the opposite direction, from the blood into the urine. Excretion of wastes The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes urea, from protein catabolism, and uric acid, from nucleic acid metabolism.

Acid-base homeostasis Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the maintenance of pH around a relatively stable value. The kidneys contribute to acid-base homeostasis by regulating bicarbonate (HCO3-) concentration. Osmolality regulation Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels. ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane allowing water to leave the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the body. There are two systems that create a hyperosmotic medulla and thus increase the body plasma volume: Urea recycling and the 'single effect. Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not. The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not permeable to water but is permeable to NaCl. This means that a countercurrent system is created whereby the medulla becomes increasingly concentrated setting up an osmotic gradient for water to follow should the aquaporins of the collecting duct be opened by ADH. Blood pressure regulation Long-term regulation of blood pressure predominantly depends upon the kidney. This primarily occurs through maintenance of the extracellular fluid compartment, the size of which depends on the plasma sodium concentration. Although the kidney cannot directly sense blood pressure, changes in the delivery of sodium and chloride to the distal part of the nephron alter the kidney's secretion of the enzyme renin. When the extracellular fluid compartment is expanded and blood pressure is high, the delivery of these ions is increased and renin secretion is decreased. Similarly, when the extracellular fluid compartment is contracted and blood pressure is low, sodium and chloride delivery is decreased and renin secretion is increased in response. Renin is the first in a series of important chemical messengers that comprise the reninangiotensin system. Changes in renin ultimately alter the output of this system, principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both increase the kidney's absorption of sodium chloride, thereby expanding the extracellular fluid compartment and raising blood pressure. When renin levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption, expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely, when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid compartment, and decreasing blood pressure. Hormone secretion The kidneys secrete a variety of hormones, including erythropoietin, calcitriol, and renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow.

Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the renal reabsorption of phosphate. Part of the renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of aldosterone levels.


Etiology: Bacteria: escherichia coli


Predisposing factors: Non-modifiable:

>urinary retention >age >diabetes mellitus >gender (female) >pregnancy >instrumentation of urinary tract >recurrent UTI

Bacteria attaches and colonizes the Epithelium of the urinary tract Antibody formation Antigen-antibody complex Fever Inflammation or trauma of urethral mucosa Nausea and vomiting

urinary tract impeded Outflow obstructed Dysuria

Frequent, scanty urination

formation of ↑ residual urine


microbial growth

Blood vessel compressed


↓ mucosal defense nocturia Inflammation of the bladder Suprapubic or pelvic pain

hematuria Vesicoureteral reflex

Flank pain

exudates fills the kidney pelvis

cloudy, foul smelling urine

Abscess and necrosis in the calyx

Loss of tubule function


Chronic Renal Failure DEATH

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