CASE STUDY

PRESENTATION ON
ACUTE PYELONEPHRITIS
Presented By:
Miss Tulsi Thapa Chhetri
B.sc. Nursing 3
rd
Year,
1
st
Batch
CONTENT
Objective of the case study
Rational for selection of the case
Health history
Family history
Family tree
Developmental Task
Physical assessment
Cont.
Disease Condition
Drug Profiles
Nursing Theory
Nursing Care
Discharge teaching
Learned from the experience
Reference

Objectives for the case study
General Objectives:
The primary concern of this study is to further
enhance the understanding of Acute
Pyelonephritis in congruence with the learned
concepts.
Contd..
The specific objectives are:

To fulfill the partial course objective

To gain in-depth knowledge about the case study
and disease.

To gain the confidence in handling such cases in
future.




Contd..
To provide holistic nursing care to the patient
by applying nursing theory.

To share experience and knowledge.

To gain the practical experiences.

To discuss physical needs and developmental
task of young adulthood.

RATIONALE FOR THE SELECTION OF
CASE:


Urinary Tract Infection is the common
disease condition in world wide.

And in context of developing countries like
Nepal, most people are lacking knowledge
and have poor personal hygiene.
Cont..
Similarly, the prevalence rate in our
hospital (Lumbini Medical College And
Teaching Hospital) during last 3 months i.e.
1
st
Magh,2070 to 1
st
Baisakh, 2071, 32
cases of Pyelonephritis were found. And
among them female=22 and male=10.

METHODOLOGY
The methodology adopted to produce this report
was based on:
History taking and interviewing to the patient
and her visitors.
Daily Assessment and, physical examination of
the patient
Discussion with teachers, senior staffs and
doctors
Using various text books and references of
Medicine and related internet search
technology.


Health History
A. PATIENT`S BIODATA
Patients Name : Mrs. Renuka Bashyal
Age/ sex: 21 yrs/female
Marital status : Married
Education: literate (+2)
Occupation: teacher
Religion: Hindu
Address (permanent): Sirsekot-8, syangja
Ward: Medical Ward
Bed: 12

Contd..
I.P. No: 38739
H.N. 40668
Date of admission: 2070/12/30
Date of interview: 2071/01/02
Diagnosis: Acute Pyelonephritis
Consultant doctor: Dr. Bishal/Dr. Shyamsudan/Dr.
Maheswor


Contd..
Date of discharge: 2071/01/06
Hospital days: 6 days
Informants: Patient (self) & her husband

B. CHIEF COMPLAIN
High grade fever with chills and rigor
since 4 days.

Pain in right flank since 3 days associated
with burning micturation.

PRESENT ILLNESS/ HEALTH
STATUS
Mrs. Renuka Bashyal was apparently fine
before 6 days. Then, symptoms like high
grade fever was suddenly developed and
pain in right flank associated with burning
micturation was also present. She came to
emergency ward of lumbini medical college
on date 2070/12/29 at 11am and after
medical consultation she was admitted in
medical ward i.e 2070/12/30.


Past Illness

Childhood Illness
Disease Yes No
Measles
Mumps


Whooping cough
Rheumatic fever
Polio
Tuberculosis
Malnutrition
Operation
Others No any other
disease
Adult Illness
Disease Yes No
Hypertension


Heart disease
Tuberculosis
Diabetes
Filariasis
Malaria
Cancer
Asthma
Accidents
Others


Contd..
2)Injuries and Accidents: Patient has no any
history of external injuries and accidents.

3)Hospitalization, Operations or Special
Treatment: She has no significant history
of previous hospitalization.

Contd..
4) Allergies:- My patient has no history of
allergy.

5) Medication Taken at Home:- She uses to
take some home remedy like gingers,
allovera etc.

Contd..

6) Traditional Healers Prescription:
According to my patient, she used to go for
the traditional health healer.

7) Medical Practioners prescription:-
According to my patient, she takes medical
practioners prescription for her health
problem.

Contd..
8) Self prescription: My patient use to take
some common medicines like paracetamol
for fevers and headache.

E. FAMILY HISTORY
There are 6 members in her family i.e. father
in-law, mother in-law, brother in-law, sister
in-law, her husband and her self.

The type of family is joint family.

There are no any such significant medical
diseases in her family.

PSYCHOLOGICAL
No any significant history of psychological
problems of the patient .

SOCIOLOGICAL:
Family Relationship: She is the smallest
member in her family.

Person Living With Client (Support
System) : Her husband and her family.
They support and love each other.

Occupational History

She is a primary level teacher and her
husband works in abroad. And recently
her husband is in vaccation of 1 month. So
he have visited home.

There are no any difficulty to over come
economic crisis.

Contd..
Leisure Time Activities:
She spends her leisure time by talking with
sister-in-law, friends & neighbours , listening
radios and watching television etc.

Chemical Use (type, frequency, problems
related to use)
Cigarettes: Non smoker
Substances :- Non user
Alcohol: Non-alcoholic

Environmental history
a) Type of Drainage System: open

b) Types of Toilet Used: Water seal

c) Sources of drinking Water: Tap water

d) Kitchen Style: Separate kitchen

e) Types of Fuel Used in Cooking: Both Gas &
fire wood


Obstetric history
Menarche: 15 years

Menopause: She is in reproductive age.

She has not given birth to any child.


Family tree





gm
gf
gm
gf
F
52
M
o
21
yrrs
32
yrs
19
yrs
14
yrs
Due to
accident 46yrs
Paternal Maternal
Patient

Developmental task of young
adulthood (20-39 years)

According to book According to the patient
Developmental task of the young
adult are:

Accepting herself and
stabilizing self concept and body
image.


She had stabilized herself self
concept and body image.
Establishing independence
from parental home and finance
aids.
She got marriage and had her
own independent job and life.
Becoming established in a
vocation or profession that
provides personal satisfaction,
economic independence.
She is economically
independent.
Contd..
Establishing an intimate bond
with another, either through
marriage or with a close
friend.
she has good relationship with
her husband and her family
members.
Establishing and managing a
residence, home
She is the smallest in the
family and is managing her
household things and works
confidently.
Formulating a meaningful
philosophy of life
Live for today because you
don't know what tomorrow may
hold.
Contd..
Becoming involved as a
citizen in the community.
she involves in the every
social function like marriage
ceremony, and other social
gathering and function.

She is the active member of
the society contributing in
social development through it.
Physical Examination
General Examination : The patient's
appearance is variable. Most commonly,
the patient is uncomfortable or appears ill.

On the abdominal examination, mild
suprapubic tenderness was detected.
Introduction to disease

Introduction:
Urinary tract infections are caused by
pathogenic microorganisms in urinary tract.

UTIs are generally classified as infections
involving the upper or lower urinary tract and
further classified as uncomplicated or
complicated.

Upper UTIs include acute or chronic
pyelonephritis, renal abscess, nephritis.
Definition:
Pyelonephritis is a bacterial infection of the
renal pelvis, tubules, and interstitial tissue
of one or both kidneys.
Epidemiology:
Women are more likely to develop kidney
infections than men because of their physical
makeup.

In women, the urethra is shorter, which allows
bacteria to spread to the bladder, and eventually,
the kidneys, more quickly.



Prevalance in Lumbini Medical College from 1
st

magh,2070 to 1
st
baisakh,2071.
69%
31%
epidemiology
Female-22 (69%)
Male-10 (31%)
Classification:
Pyelonephritis
Acute Pyelonephritis Chronic Pyelonephritis
Acute Pyelonephritis:
Acute pyelonephritis is
an exudative purulent localized inflammation of
the renal pelvis (collecting system) and kidney.

The renal parenchyma presents in the
interstitium abscesses (suppurative necrosis),
consisting in purulent exudate (pus):
neutrophils, fibrin, cell debris and central germ
colonies (hematoxylinophils). .
Chronic Pyelonephritis:
Chronic pyelonephritis implies recurrent
kidney infections, and can result
in scarring of the renal parenchyma and
impaired function, especially in the setting
of obstruction.

A perinephric abscess (infection around the
kidney) and pyonephrosis may develop in
severe cases of pyelonephritis.
Risk Factors:
Conditions such as kidney stones or BPH
(enlarged prostate), which make it more
difficult for the body to manage urine flow.

Congenital (present at birth) abnormalities of
the urinary tract.

Patient history of urinary tract infections
(UTIs) or a certain type of bacteria.
Contd..
Spinal cord injury (may prevent patients from
experiencing pain and other symptoms of
kidney infection)

Vesicoureteral reflux (VUR; causes urine to
back up from the bladder into the kidneys)


Cause:
Escherichia coli is the most common
causative agent of this infection.

Other bacteria that can trigger the kidney
infection are; Pseudomonas, Proteus,
Streptococcus faecalis and Staphylococcus
aureus.
Pathophysiology:
Ascending infection of the
urinary tract(Escherichia coli)

Infection reaches pelvis and kidney

Interstitial abscesses present in the parenchyma

Renal tubules are damage by exudates

Inflammation of renal pelvis and kidney

Clinical Manifestations:
According to book According to patient
Chills, fever present
leukcytosis Total WBC count- 15800/cumm
Costovertebral angle pain Pain in right flank region
Nausea and vomiting Nausea acompained by anorexia
Burning and frequency of micturation present
Diagnosis:
According to Book According to my patient
Physical examination


-temperature-103.4 f
-mild suprapubic tenderness
-dehydrated
Ultrasonography -uterus containing a tiny sac with
decidual reaction seen.
-but pregnancy test was negative.
Haematology -WBC count- 15800/Cumm
-Hb-8.8gm%
Urinalysis -pus cells: 16/HPF
-epithelial cells-0-2/HPF
Urine Culture -bacterial growth
Cont..
Computerized Tomography scan Not done
Intravenous Pyelogram Not done
Management:
Medical management

Nursing management
Medical Management:
According to book According to patient
Drug Therapy
Broad spectrum antibiotic

Inj. Ceftriaxone 1 gm Intravenous
Fluid intake of at least 2L/day Increased fluid intake (oral + IV fluid)
Regular complete emptying of bladder Done
Intake of cranberry juice Done
Drugs Used In My Patient:
Inj. Ceftriaxone 1 gm IV
Tab. Paracetamol 500 mg PO TDS
Tab. Ifol 1 tab PO OD

Discharge Medicine:
Tab. Cefixime 200mg PO BD for 7 days
Tab. Orofer 1 tab PO OD
Syp.Urisetrol 2 tsp PO TDS


Nursing Management

Nursing Theory

Orems General Theory of Nursing:
Includes: Theory of self care, self care deficit
and nursing system.

1.Theory of Self care:
Self care : maintain personal wellbeing
Self care agency: Family, Health care System
Therapeutic self care demand: totality of self-
care actions to be performed
Self care requisites (universal, developmental
and health deviation )

Cont..
The theory of Self care deficit:
It is identified by the nurse through the
thorough assessment
Care is provided by supportive and
educative system.

Care provided through:

Acting,
guiding,
supporting,
providing an environment that promotes
personal development,
Teaching

Theory of Nursing system :
Wholly compensatory: Who are unable to
participate in self care.

Partially compensatory: Nurses assist client
as needed.

Supportive educative: Nurses role is to
monitor and regulate clients self care.

Application of theory of self-care
deficit:
I n My patient:
My patient was able to do the activities of
daily living but need assistant and education
for her due to weakness.

She need some universal self care requisites.

So, I applied supportive - educative of
nursing care to accomplish need of my
patient.

Data Collection According To
OREMS THEORY :
Age: 21 year

Health state: partial disability due to health
condition

Development State: Generativity vs.
Stagnation

Cont..
Sociocultural orientation: literate ,
middle class family , Hindu

Health Care system: Institutional health
care

Family system: Married, lives with family
Cont..
Patterns of living: Lives with family

Environment: Safe environment

Resources: Self and family member

Universal Self care requisites:
Air
Water
Food
Elimination
Activity/ rest
Social interaction
Prevention of hazards


Developmental self care
requisites:
1. Maintenance of developmental
environment: able to feed self but needs
assistance in performing some of her daily
life activities.

2. Prevention and management of the
condition threatening the normal
development: feels curious about her
disease and discusses about problems with
family members.

Health deviation self care
requisites:
1. Adherence to medical regimen.
2. Awareness of potential problems
associated with regimen.
3. Modification of self.
4. Adjustment of lifestyle to accommodate
changes in the health status and medical
regimen.

Application of theory:
Areas of deficit were:

Activity/Rest
Food/Fluid
Elimination
Preventive hazards

Nursing Diagnosis:
1.Acute Pain related to inflammation and
infection of the urethra, bladder and other
urinary tract structures.

2.Impaired Urinary Elimination
related to frequent urination, urgency, and
hesitancy.

3.Disturbed Sleep Pattern
related to pain and nocturia.




Cont..

4.Imbalanced Nutrition, less than body
requirements related to anorexia.

5.Risk for Fluid Volume Deficit
related to excessive evaporation and vomiting.

Cont.

6.Anxiety related to crisis situations, coping
mechanisms are ineffective.

7.Knowledge Deficit about condition,
prognosis, and treatment needs
related to the lack of resources.


Nursing care plan through theory
application:
1) Deficit area: Activity/Rest
Adequacy of self-care: Inadequate

Nursing diagnosis: Acute pain related to
acute inflammation of renal tissues.

Goal:
1. To make the patient relieve from pain.

Cont..
Objectives :
Patient will verbalize relief of pain and
discomfort.
Patient will show calm facial expression.

Design of the nursing system:
Partially compensatory and supportive
educative



Cont.
Method of helping:
Guidance
Support
Teaching

Cont..
Interventions:
Assessed pain, noting location, characteristics,
intensity (0-10 scale).
urine flow and its characteristics was observed.
Provided comfort measure like back rub or
deep breathing exercises.
Assisted with range of motion exercises and
encourage ambulation.
Administered analgesics as per the physicians
order.

Cont..
Evaluation:
She demonstrated reduction of the pain
behaviors.
She verbalized an improved comfort.
The supportive educative system was
useful.

Nursing care:
DATE/TIME COURSE IN THE WARD
Admission Day:
2070/12/30 at 11 am.
-admission done
-cold sponging done for fever
management.
-Paracetamol 500mg given.
2071/01/01 -assisted patient in performing daily
activities.
-encouraged for the intake of fluids.
2071/01/02 -as she was in iv medication, provided iv
site care.
-history taking, physical examination done.
2071/01/03 -informal health teaching on infection
prevention.
-provided medication as per
presciption.
2071/01/04 -assisted in basic care.
-also encouraged for the intake of
cranberry juice.
2071/01/05 -observed the progress of the treatment.
-planned discharge on following day.
Discharge Day
2071/01/06
-discharge teaching given.
-informed about the follow up after 2
weeks.
Discharge Teaching:
MEDICATION-Strict compliance to medication
regimen-Antibiotics for 7 days .

EXERCISE/ENVIRONMENT-instruct the client
on ways how to maintain the cleanliness of
her environment.

TREATMENT-practice kegel exercise.
Cont..
HEALTH TEACHING:
Keep the genital area clean by wiping from
front to back, it helps reduce the chance of
introducing bacteria from the rectal area to
the urethra.

OUT PATIENT FOLLOW UP CARE:
instructed patient to visit OPD for followup
after 2 weeks.
References:
Suddarths and Brunner , Textbook of Medical-
Surgical Nursing 12
th
Edition Wolter Kluwer/
Lippincott Williams and Wilkins.
Black, J.M., Hawks, J.H., & Annabelle, M.K.
(2005). Medical-Surgical Nursing-clinical
management for positive outcomes.(6th ed.).
Sharma Muna, Nursing Concepts and Principles
First Edition, Medhavi Publication.
www.google.com/Acute pyelonephritis-wikipedia