Case-Study-Final-1 BOSET NA CASE PRESENTATION

VISION MISSION
A premier inclusive university of The Our Lady of Fatima

choice aspiring to improve man University, together with Fatima
as man by developing Medical Science Foundation, Inc.
individuals through a legacy of Is dedicated to the improvement of
excellent education and man as man through the holistic
compassionate value formation. formation of individuals imbued
with knowlegde, skills, and virtues
2nd Semester AY: 2019-2020
NURSING CARE OF THE CLIENT WITH ACUTE PYELONEPHRITIS IN

PREGNANCY
A Case Study Presented to the Faculty

Of OLFU College of Nursing
In Partial Fulfillment of the Requirement in NCM 219 OB for the Degree,

Bachelor of Science in Nursing
Presented by:
GROUP 18
BSN 2A2-4
Presented to:
Daisy Y, Yadan, MAN,RN
Clinical Instructor
Nelia R. Capulong MAN, RN, RM
Dean, College of Nursing
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NURSING CARE OF THE CLIENT WITH ACUTE PYELONEPHRITIS IN PREGNANCY
TABLE OF CONTENTS
Chapter 1: INTRODUCTION
Background of the Study
General objectives ..…………….………..………………………………….4

Specific Objectives............................................4
Background of the study..........................................4
Cognitive………………………………………………...………………………………………...5
Psychomotor……………………………………………………………………………………….5
Affective…………………………………………………………………………………………...5
Significance of the Study………………………...
………………………………………………...6
Chapter 2: REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY
I. DEMOGRAPHIC DATA…………………...…………………………………………………7
II. REASON FOR SEEKING HEALTH CARE…………..………………………………………7
III. HISTORY OF PRESENT ILLNESS…………...
……………………………………………...8
IV. Past Medical History……………………...…………………………………………………...8
V. Heredo-Familial History……………………...………………………………………………9
VI. SOCIO-ECONOMIC HISTORY……………...……………………………………………..11
VII. .Developmental History……………………...……………………………………………...11
A. E. Erikson’s Psychosocial Development.......…………………………………………………11
B. L. Kholberg’s Moral Development………….......
…………………………………………….12
VII. Gordon’s 11 Functional Health Patterns………………...…………………………………..13
Chapter 3: RESULTS DISCUSSION: ANALYSIS AND INTERPRETATION

WITH CLINICAL IMPLICATION AND SIGNIFICANCE
I. Comprehensive Physical Examination……………………………………………..……….21
2
II. Diagnostic Test…………………………………………………...…………………………...25
III. Review of System…………………………………………...………………………………29
Chapter 4: SYNTHESIZING FRAMEWORKS, INFERENCE,ACTION PLANS AND

CASE REFLECTIONS
I. Pathophysiologic Framework………………………………………………..………………..31
II. Case Management…………………………………………………...………..………………34
Medical Management…………………………………………………………………………34
1. Pharmacologic Intervention…………………………….......…………………………………34
III. Plans for Nursing Actions………………………...…………...
……………………………...32
A. Course in the ward……………………………...……..………………………………………32
B. Nursing Care Plan………………...…………………………………………………………...49
C. Discharge plan………………………………………………………………………………...54
References………...……………………………………………………………………………..55.
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Chapter 1: Introduction
I. Objectives
 General Objectives
This research focuses on the advancement of our skills in administering and enhance
our understanding regarding to acute pyelonephritis.
 Specific Objectives
1. To be able to establish good relationship with the patient,
significant others, staff and member of the health care team.
2. To be able to identify and provide measures to manage the patients
present health problem.
3. To be able to provide a quality nursing care of the patient based on
the prioritization of needs.
4. To prevent complication of Acute Pyelonephritis.
5. To render patients the quality nursing care all throughout the stay
of the patient in the hospital.
6. To understand the structures and normal function of the body organ
involved.
7. To be familiar with the client’s medications that includes the
therapeutic and adverse effects and the significance to the
disease/condition.
II. Back ground of the Study
Acute Pyelonephritis is a bacterial infection causing inflammation of the kidneys

and is one of the most common diseases of the kidney. Pyelonephritis occurs as a
complication of an ascending urinary tract infection (UTI) which spreads form the
bladder to the kidneys and their collecting systems. Symptoms usually include fever,
flank pain, nausea, vomiting, burning on urination, increased frequency and urgency.
The 2 most common symptoms are usually fever and flank pain. Acute Pyelonephritis
can be divided into complicated and uncomplicated. Complicated Pyelonephritis
includes pregnant patient’s, patients with uncontrolled diabetes, kidney transplants,
urinary anatomical abnormalities, acute chronic kidney failure as well as
immunocomprised patients and those with hospital acquired bacterial infection.
The main cause of acute pyelonephritis is gram-negative bacteria, the most common
being Escherichia coli. Other gram-negative bacteria which cause acute pyelonephritis
include Proteus, Klebsiella and Enterobacteria. In most patients, the infecting
organism will come from their fecal floral. Bacteria can reach the kidney in two ways:
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hematogenous spread and is less common and usually occurs in patients with ureteral
obstructions or immunocomprised and debilitate patients. Most patients will get acute
pyelonephritis through ascending infection. Ascending infection happens through
several steps. Bacterial will first attach to urethral mucosal wither through
instrumentation or UTI which occur more frequently in females. UTIs are more
common in females than in male due to shorter urethras, hormonal changes, and close
distance to the anus, urinary tract obstruction caused by something such as a kidney
stone can also lead to acute pyelonephritis. An outflow obstruction of urine can lead
to incomplete emptying and urinary stasis which causes bacteria to multiply without
being flushed out. A less common cause of acute pyelonephritis is vesicoureteral
reflux, which is a congenital condition where urine flows backward from the bladder
to the kidneys.
Purpose of the Study

Specific
 Cognitive
- To initiate specific idea for plan of care and intervention to provide the
needs of the clients primary regarding to any decision or activities
affecting their care based on the assessment of the disease.
 Psychomotor
- Apply the nursing process to identify nursing problems and provide the
proper nursing care plan. Assess efficacy of performed nursing
interventions.
- Provide and document important interventions to the client
 Affective
- Develop therapeutic communication to the patient and to her family,
practice nice way on how to get along with the patient in respectful and
proper manners.
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Significance of the Study
Patient
- This case study will help the patient to analyze the clinical content and the
related factors of the disease during and after the course of the treatment
Family
- This case study will help the family to understand on how they will
cooperate to treat the patient unconditionally and to show their family support
during the course of the illness and the treatment of the client.
Student
- This study will help the students to know the implications factors, etiology
and nursing practice that needs to be comprehend and deliver to a patient
whose suffering from acute pyelonephritis
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Chapter 2: REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY
I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name XX
B. Address Citrus, QC3 Bulacan City
C. Age 15 years old
D. Birth date February 19, 2004
E. Birth Place Ospital ng San Jose Del Monte
F. Gender Female
G. Civil Status Single
H. Religion Catholic
I. Highest Educational Attainment Grade 8
J. Occupation None
K. Monthly Income/ Budget None
L. Date of Admission December 3, 2019 (Tuesday)
M. Date of Interview December 4, 2019 (Wednesday)
N. Primary Informant Patient XX
O. Secondary Informant Mother-in-Law/ Grandmother
P. Other data sources Patient’s chart
II. REASON FOR SEEKING HEALTH CARE
The client sought for consultation due to persistent symptoms of pain on the right
lower quadrant of her abdomen and fever for 3 days.
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III. HISTORY OF PRESENT ILLNESS
Last December 2, the patient suddenly experienced pain on the right lower
quadrant of her abdomen wherein she assumes that this is a sign of impending
miscarriage.
After that day, the patient immediately decided to seek health care at Ospital ng
Lungsod ng San Jose Delmonte because she cannot tolerate the pain and also in fear
of losing her child.
During her stay in the hospital, she was admitted and accompanied by her auntie.
They were asked to perform laboratory results such as CBC, U/A, UTZ
IV. PAST MEDICAL HISTORY
She had BCG vaccine and other immunizations were unrecalled. She had 1 dose
of tetanus toxoid and HIV on her pre-natal check ups. Her previous hospitalization is
due to Urinary Tract Infection (UTI) when she was 15, where she had to take
antibiotic. She had no record of blood transfusion prior to her condition. In terms of
psychiatric status, she had no violence, drug overdose, but she once had the idea of
suicidal attempt due to sadness.
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V.HEREDO- FAMILIAL HISTORY
A. Genogram
Legend:
Health Implication:
This heredo-familial history shows that the common hereditary diseases that the
family has inherited are
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B. Family APGAR
Evaluation Questions Almost Some of the Hardly

Constructs always (2) time (1) ever (0)
Adaptation I am satisfied with the help
that I receive from my
/
family when something is
troubling me.
Partnership I am satisfied with the way
my family discusses items of
/
common interest and shares
problem- solving with me.
Growth I find that my family accepts
my wishes to take on new
/
activities or make changes in
lifestyle.
Affection I am satisfied with the way
my family expresses
affection and responds to my /
feelings such as anger,
sorrow and love.
Resolve I am satisfied with the way
my family and I spend time /
together
Total 6
0-3 = Low 4-7 = Moderate 8-10 = High
Health Implication:
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The result of her family APGAR is 6. This shows that despite the presence of the
illness of the patient affects her social life, development, affection and the way she
bonds with her family. Also the patient feels that her family didn’t want her to be
involved on problem-solving because they didn’t want to feel any stress/ thinking
about problems that may lead to some psychiatric situations/ problems.
VI: SOCIO-ECONOMIC HISTORY
Patient XX is the youngest in her 3 siblings. She is a non-employed woman since she
dropped highschool because of being pregnant. Her civil status is single, but she is
living with her family’s boyfriend in Citrus CQ3,The source of their water was a
public faucet, The cleanliness of their community was maintained due to regular
collection of garbage every wednesday by garbage trucks. For the economic condition
her father in law helped her for expenses such as hospital bills,medications,house
expenses, etc. With the amount of 1,500 pesos a day which was given day by her
father in law
(with permission to the client). her favorite habits are using cellphone, and playing
badminton (back then when she was active in sports).
VII: DEVELOPMENTAL HISTORY
A. Erick Erikson’s psychosocial Development
Stage &
Evidences of Milestone
Functional Task
achievement
Age
Identity  Close relationship - she mentioned that she isn’t
with friends and contented the way her mother
Vs.
family treated her she thinks that her
Role confusion mother always favoring her other
siblings than her.
-The patient mentioned that she is

close with her friends and they
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always spends a lot of times
Health implication :
This shows that patient XX is in the identity side (role confusion)of Erik erickson’s
stage six of development the patient verbalized that she is not close to her parents
because she’s not secure and contented with her family side which is the opposite into
her way she treats her friends.
B. L.Kholberg’s moral development
Stage &
functional Task Evidences of milestone
Age
Conventional In stage 4 the child bindly accepts rules The Patient XX. accepts
and convention because of their her child and also the
(law & order
importance in maintaining a functioning family of her boyfriend.
orientation)
society.Rules are seen as being the same Patient believes that she
for everyone and obeying rules by doing don’t have the rights to kill
what one is supposed to do is seen as someone’s life by having
valuable and important. Moral abortion because God
reasoning in stage 4 is beyond the need created us to fulfill our
for individual approval exbibited in responsibilities,rules and
stage 3. If one person violates a law, laws as human and as
perhaps everyone would-thus there is an follower of God.therefore
obligation and a duty to uphold laws as a human, with faith the
and rules. patient knows she has the
responsibility to take care
and give love to her child
inside her womb
Health implication:
These shows that patient XX will do her responsibility on the child inside her.
She believes that God gave her a child to take care, and do an obligation to be a
mother.
VIII.Gordon’s 11 Functional health Management

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A. Health Perception-Health Management
before hospitalization During hospitalization

 Patient XX wasn’t prioritize
her health all she wanted is to
spend time to her friends and
 During our interview patient XX believed
do activities like play online
and know the importance of having good and
games.
nutritious eating habit and know the values of
 November 5,2019 she was taking vitamins especially she is pregnant and
suffered pain during and after followed orders by her physician.
her urination and sought a
 She had conscious of health and followed
consultation together her in
what are good recommendations that she take
laws and they found out she
and also think what are the possibility happened
had UTI (urinary tract
that reflect to her child.
infection) the physician
 Patient XX was able to follow her
prescribed a metronidazole
physician or health provider suggestion about
cefuroxime
her medication and limits necessary activities
 November 12, 2019 after
and promote good perception about her health
taking up for 1 day medication
and the importance of stress free in order to be
patient J.A was not able
relaxed during her pregnancy
suffered from pain during/after
his urination and she feel well
to her illness  She had cough during her hospital stay.
 She drink alcoholic beverages

occasionally
Health Implications:
At her young age she was diagnosed with this kind of illness especially she was
pregnant but the positivity of the patient are powered that she can face it and
surpassed all of that mentioned. And she already knows the importance of prenatal
check-up and having vitamins and good eating habit that make her health improve and
follow all physician orders by maintaining in good status and prevent any infection in
the near future of during delivery.
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B.Nutritional- Metabolic
Before hospitalization During hospitalization

 Patient XX had a poor  patient XX had restriction of her diet, especially
eating habit. In the the physician order her to low in salt & fat diet and
morning she eat bread for need immediate increase his healthy lifestyle
her breakfast before she especially during his pregnancy state.
can do her daily activities.
 The patient usually waking up at 8:30am and
She drinks an average of 8
she eat soups and porridge. Her lunch is chicken
glasses of fluid per day.
soup (tinola), She had a snack during late afternoon.
Health implications:
This signifies that patient J.A become more restrict about her food that she eat
after being diagnosed and she need to follow all prescriptions and advice by her
physician in order to maintain her good health and prevent any abnormalities may
occured during her pregnancy and understand the importance of having healthy
nutritional habits.
C. Elimination

 Patient XX defecates once a day  Patient XX verbalize that during her
and urinates 3-6 times a day stay to the hospital she did not defecate and
she urinates 6-8 times a day.
Health Implication:
The signifies that though her elimination was not as exactly the same as before
being diagnosed, her body is still able to function and eliminates the toxic waste in her
body
D. Activity- Exercise

 According to the patient she has  Patient XX has enough energy to do
enough energy even though she is same task,she managed to walk,she can’t
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pregnant she still be able to sweep do heavy task because she is pregnant
their home
Health implication:
Patient XX was able to walk with support. She was not able to do some heavy
task due to her condition
*Katz Index of Independence in Activities of Daily Living During

Hospitalization:
Activities Independence=1 point Dependence-0 point
Points (1 or 0) No supervision,direction or With supervision,direction or

personal assistance needed personal assistance or total care
Bathing /
dressing /
toileting /
transferring /
continence /
feeding /
TOTAL POINTS: 5
Health implication:
With the scoring of Katz Index of independence in ADL shows above that the
patient do not need supervision and direct assistance of care. She was able to perform
daily activities and she has hobby of doing household chores.
E. Sleep-Rest

 Patient XX reported that she has  Patient usually sleeps at 10:30pm
enough rest because she stop because she often browse her cellphone
schooling due to pregnancy. She and she usually takes a nap at the daytime
sleep at 10:00 pm and wake up at particularly after lunch.
8:30 am in the morning, she has an
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average of 12 hrs of sleep everyday.  She easily falls asleep but awakens
during the night because of the urge to
 When the pain started on her right
void.
lower quadrant, she had difficulty in
sleeping on December 2, 2019
Monday then on morning she rushed
to the hospital.
Health implication:
This implies that the patient had more sleeping hours before hospitalization.
F. Cognitive-perceptual

 The patient XX does not participate in  When it comes in making decision
decision making regarding their family the family want to participate but the
matters, not also share her ideas, patient doesn’t want to,
experience, and thoughts when she
 Patient XX was assessed for any
was in school as well as in their house.
changes in memory, we asked about her
 She had no problem with recalling experienced before she got pregnant, but
recent memories. she can’t tell us directly because her
family is listening.
 She doesn't have hearing and vision
problem. Even her surrounding is too  She doesn't have hearing and vision
noisy. problem. Because she can understand
the question. Although her family
joining the interview.
Health implication:
This implies that the patient XX has no problem with her senses and no problem
of her cognitive perception.
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G. Self-perception-self concept

 For the patient XX her role to her  The patient answered the question
family and friends are important. but not directly because her
but her parents told us when she relatives is in front of her when
was in grade 8, she wasn't asked if she still feels good about
studying well and she is hanging herself. She agreed by nodding.
out with her friends at night and  The patient couldn't do eye to eye
going home late and until her contact while doing the interview.
parents knows she is pregnant and
she stopped studying but after she
give birth she plan on going back
to school.
Health implication:
This implies that the patient XX knows her own behavior has her observable actions
reflects herself image and preference.
H. Role -relationship

 Patient XX lives with her family. She  She wasn’t able to help in their daily
was the youngest daughter and able chores due to her sensitive pregnancy.
to help with their basic needs. She had to take a bed rest as prescribed
by her physician.
 She was a former grade 8 student in a
public school because she had to  Due to her confinement, she would
withdraw due to her pregnancy. be given easy tasks at home.
Health implication:
This signifies that patient XX has difficulty in performing her daily task due to
her sensitive pregnancy to prevent future miscarriage, so she wasn’t able to perform
her role to her family.
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I. Sexuality Reproductive

 the patient menstrual cycle is regular  The patient menstruation has already
and reported that she had no stopped due to pregnancy
menstrual period
 Patient is not sexually active
 Patient is sexually active
Health implication:
The patient menstrual cycle is regular until pregnancy started
J. Coping-stress

 Develop therapeutic communication  According to her, she doesn’t feel
to the patient and to her family, any stress during her hospitalization,
practice nice way on how to get
along with the patient in respectful but at first when the symptoms occur
and proper manners. she was scared that she might lose
her baby but her family was there to
support and comfort her so she felt
better.
Health implication:
This implies that the patient had become more comfortable in sharing her feelings
and thoughts to her family regarding stress and problems she is facing.
K. Value Belief pattern

 Patient XX mentioned that she  Patient XX asks for guidance through
always prays but she never goes to prayer at these times because they believe
church because she believes that it is that God will be the one who will help
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just the same. them.
Health implication:
This shows that patient J. A despite of her condition her faith becomes stronger
and deeper.
Chapter 3: EVALUATION RESULTS INTERPRETATION, ANALYSIS,

HEALTH IMPLICATION & CLINICAL SIGNIFICANCE
I. Comprehensive Physical Examination

Date / Time of Exam: September 4, 2019 10:00 am
A. Vital Signs
T = 36OC
PR = 66bpm
RR = 20cpm
BP = 90/70mmHg
B. Anthropometric Data (only those applicable)
Height 156cm
Weight 44 kgs
Body Mass Index (BMI) 18.1 = UNDERWEIGHT
Health Implication:
This represents that the patient’s weighted 44 kgs is not ideal to her height of 156cm.
The body mass index (BMI) of the patient is 18.1 which is classified as underweight.
C. General Appearance
Body build and height – weight The weight is low that it's not accurate to the
proportionality height of the patient.
Posture and Gait can stand and sits upright and can walk with no
problem
Over-all hygiene and grooming no body odor and no unnecessary breath odor
without proper grooming.
Obvious signs of distress / illness No obvious signs of distress / illness
Mental status Conscious, coherent
Attitude Cooperative, attentive
Affect/mood; appropriateness of Appropriate to situation
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responses
Quantity and quality of speech Understandable, have association of thoughts
Health Implication:
This signifies that most of the patient general appearance are normal.
Focused Assessment
December 4,2019
Normal Finding Actual Finding Clinical

Body Part Examined Significance
INTEGUMENTARY NORMAL
Skin Evenly colored Skin tone is

I: color, uniformity, skin tones without brown in color
edema, lesions unusual or and even, with a
prominent scar at the left
discoloration forearm
P: moisture, temperature, Skin surfaces vary skin is smooth NORMAL
good turgor from moist to dry and even with no
depending on the lesion. the
area assess, temperature is
normally warm warm with no
temperature, skin edema. skin is
mobile, with mobile, elastic
elasticity and and quickly return
returns to original to original shape
shape quickly
Hair and scalp The color of hair is Hair is copper NOT
I: general color and determined by the brown due to hair NORMAL
condition of scalp and amount of melanin dye
hair only small
present. natural
amount of hair
hair color as
dye may be
opposed to
absorbed by
chemically colored
the skin that
hair varies among
would be able
clients from pale
to reach the
blond to black to
fetus
gray or white
P: smoothness Smooth and firm Hair is dull and NORMAL
somewhat elastic, dry, scalp is clean
scalp is clean and
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dry. and dry
Nails Nails are clean and Nails are not NORMAL
I: grooming and pink tone should be clean with nail
cleanliness, color and seen. There is polished on other
markings, shape. normally a 160- nails and with
degree angle pink tone and
between the nail long nails
base and the skin
P: Blanch test or Nails are hard and Nails are hard and NORMAL
capillary refill, assess basically immobile, pink tone returns
texture pink tone returns immediately to
immediately to blanched nail bed
blanched nail bed when pressure is
when pressure is release
release
EARS and HEARING Absence of lesions, No lesion or pus NORMAL
ears are but seen with dry
External canal for symmetrical. the cerumen during
cerumen, lesion, pus or auricle aligns with inspection
blood the corner of each
eye and within a
10-degree angle of
the vertical
position. earlobes
may be free
attached
HEAD and FACE Head size and Head is NORMAL
shape vary, normocephalic
I: size, shape and especially in accord and no lesion seen
configuration of head, with ethnicity.
inspect symmetry, Usually the head is
movement, expression symmetric, round,
and skin condition.
erect, and in
midline and
appropriately
related to body size
(normocephalic).
No lesion is visible.
EYES: Pupils are normally Pupils are equal, NORMAL
I: pupils assess for equal, round, round and
pupillary response using reactive to light reactive to light
PERRLA accommodation. accommodation.
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Mouth / Oropharynx Lips are smooth Lips are dry but NORMAL
I: lips and without lesions pink in
Observe lip consistency and swelling appearance
and color without lesions or
swelling
I: teeth Thirty-two pearly The patient has 5
Note the number of whitish teeth with missing teeth,
teeth, color, and NOT
smooth surfaces yellowish color in
condition. Note any NORMAL
and edges. No appearance with
repairs such as crowns decayed areas; no cavities Poor oral
and any cosmetics such missing teeth. hygiene
as veneers
Client may have
evidence of repair
work done on teeth
I: gums The color and The gums are NORMAL
Retract the client’s lips consistency of pink, moist, and
and cheeks to check tissues along firm, lesions and
gums for color and cheeks and gums masses are not
consistency are even, Gums are present.
pink, moist, and
firm. No lesions or
masses
I: tongue The tongue should The tongue are NORMAL
Inspect for color, be pink, moderate pink, moderate in
moister, size, and texture in size with size, moves
papillae, moves freely, No lesions
freely, No lesions upon inspection
or nodules.
NECK Neck is symmetric, Non palpable and NORMAL
with head centered No enlargement
P: make note of level of and without of lymph nodes,
any lymph nodes and bulging masses. During palpation.
any increase in size Non palpable
lymph nodes, no
enlargement.
THORAX & LUNGS NORMAL
Posterior Thorax
I: Inspect: shape and
symmetry from
posterior-lateral views,
spinal alignment for
deformities
NORMAL
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Pe: percuss for Excursion is Excursion is
diaphragmatic excursion. equally bilateral equally bilateral
Percuss the intercostal and the level of and the level of
space at the right diaphragm is diaphragm is
posterior chest wall higher on the right higher on the NORMAL
side because of the right side because
A: auscultate for breath positiom of the of the positiom of
sounds liver. the liver.
Normal breath soun Patient’s breath

may be sound is
auscultated- bronchovesicular.
bronchial,
bronchovesicular
and vesicular
Spine No deformities, No Thoracic NORMAL
tenderness and Kyphosis, no
I: structure, deformity swelling. tenderness and
Smoothness of swelling. Limited
P: edema, tenderness
movement. spinal movement.
Anterior Thorax No adventitious No adventitious NORMAL
A: anterior breath sounds, such as sounds, such as
sounds, adventitious crackles or crackles or
sounds, voice sounds wheezes. wheezes heard.
ABDOMEN Abdominal skin Abdomen doesn’t NORMAL

I: Observed the may be paler than have scar, lesions
coloration of the skin, the general skin and rashes. The
inspect for scar, assess tone because this Fundic height is
for lesion and rashes skin is so seldom 28cm. Linea nigra
exposed to the is visible due to
natural elements. pregnancy.
MUSCULOSKELETA Knee is symmetric Knee is NORMAL
L hollows present on symmetric
Muscles both sides of the hollows present
patella. No on both sides of
swelling or the patella. No
I: Shoulder: inspect for deformities. swelling or
size, shape, symmetry, deformities.
swelling, deformities,
and alignment.
NEUROLOGIC Client is alert and Client is alert and NORMAL

Mental Status oriented to what is oriented to what
Observe the client’s happening at the is happening at
level of consciousness time of interview the time of
and physical interview and
assessment. physical
Responds to your assessment.
questions and Responds to your
interacts questions and
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appropriately interacts
appropriately
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III. Diagnostic Test
HEMATOLOGY RESULT December 03, 2019

Complete Normal Result Interpretation Analysis
Blood Count
Hemoglobin 120-150 mg/dL 98 Abnormally Decrease of
Low hemoglobin means
presence of anemia.
Hematocrit 0.37-0.47 0.30 Abnormally Decrease of hematocrit
Low means presence of
anemia.
Red Blood Cell
Count
White Blood 5-10x10 7.8 Normal Normal
Cell Count
Bleeding Time 1-5 mins
Clotting Time 1-5 mins
Blood Typing 3.70-10.1
Segmenters 0.55-0.65 0.79 Abnormally There is a presence of
High bacterial infection
Lymphocytes 0.25-0.35 0.19 Abnormally Lymphocyte counts

Low below the normal range
can also be temporary.
They can occur after a
cold or another infection,
or be caused by intense
physical exercise, severe
stress, or malnutrition.
A low level can also be a
sign of a condition
known as
lymphocytopenia or
lymphopenia
Eosinophils 0.00-0.05 0.02 Normal Normal
Monocytes 0.00-0.06
Basophils 0.00-0.01
Stabs
Pateletcount 150-350 mm 300 Normal Normal
25
Hematology Result December 06, 2019
Complete Normal Result Interpretation Analysis
Blood Count
Hemoglobin 120-150 mg/dL 101 Abnormally Decrease of
Low hemoglobin means
presence of anemia.
Hematocrit 0.37-0.47 0.31 Abnormally Decrease of hematocrit
Low means presence of
anemia.
Red Blood Cell
Count
White Blood 5-10x10 8.5 Normal Normal
Cell Count
Bleeding Time 1-5 mins
Clotting Time 1-5 mins
Blood Typing 3.70-10.1
Differential
Count
Segmenters 0.55-0.65 0.65 Normal Normal
Lymphocytes 0.25-0.35 0.35 Normal Normal

Eosinophils 0.00-0.05
Monocytes 0.00-0.06
Basophils 0.00-0.01
Stabs
Pateletcount 150-350 mm 230 Normal Normal
URINALYSIS
Macroscopic Result Result Analysis
(December 03, (December 06,
2019) 2019)
Color Yellow Yellow Normal
Transparency Slightly Turbid Hazy December 3, 2019
Turbid because of the
presence of pus cells.
December 6, 2019
Hazy because the
presence of pus and
bacteria are
26
decreased
Reaction Acidic Acidic Normal
Specific Gravity 1.010 1.010
Protein Negative Negative N/A
Sugar Negative Negative N/A
Red Blood Cells 2-3/hpf 0-2/hpf Normal
Pus Cells 40-45/hpf 5-7/hpf
Epithelial Cells +++ ++ December 3, 2019
Severe presence of
epithelial cells
indicates urinary
tract infection.
December 6, 2019
Normal
Bacteria +++ + December 3, 2019
Severe bacteria
indicates presence of
infection
December 6, 2019
Normal
Mucus Thread N/A N/A
Amorphous Urate N/A N/A N/A
Transvaginal Ultrasound Taken on December 04, 2019
Impression:
Single alive intrauterine pregnancy in breech presentation of about 28 week
age of gestation by fetal biometry normohydramnios.
27
III. Review of System
ANATOMY OF THE KIDNEY
28
The kidney, as a major excretory organ, is crucial in maintaining an optimal
internal environment. The kidney eliminates a variety of metabolic products (urea,
uric acid, and creatinine) and conserves and excretes water and electrolytes. It also
stimulates erythrocyte production by producing the erythropoietin.
The kidneys are 11 centimeters long, paired, reddish brown organs situated on the
posterior wall of the abdominal cavity, one on each side of the vertebral column and
capped by the adrenal gland. Due to the presence of the liver, the right kidney is
slightly lower than the left kidney. The kidneys are located between muscles of the
back and the peritoneal cavity.
The functional unit of the kidney is called the nephron. There are approximately 1
million nephrons in each kidney. Each nephron is consisting of two parts: a
glomerulus (a network of capillaries) and a tubule. The tubule is an elongated hollow
duct with the proximal end forming a double walled cap known as the Bowman’s
capsule. Another part of the tubule twists and folds and another straightens after
folding back in itself and yet another one forms characteristic loops. These are the
proximal and distal convoluted tubules and the loop of Henle.
The urinary bladder,a muscular sac in the pelvis, just above and behind the pubic
bone. When empty, the bladder is about the size and shape of a pear.
ANATOMY OF THE URINARY BLADDER
29
Urine is made in the kidneys and travels down two tubes called ureters to the
bladder. The bladder stores urine, allowing urination to be infrequent and controlled.
The bladder is lined by layers of muscle tissue that stretch to hold urine. The normal
capacity of the bladder is 400-600 mL. like the stomach, is an expandable saclike
organ that contracts when it is empty. The inner lining of the bladder tucks into the
folds and expands out to accommodate liquid.
The bladder is connected to the kidneys by two long tubes called ureters. When
urine is produced by the kidneys, it travels down the ureters to the bladder, where it is
stored.
30
CHAPTER 4: SYNTHESIZING FRAMEWORKS, INFERENCE,
ACTION PLANS AND CASE REFLECTIONS
I. Pathophysiologic Framework
ETIOLOGY: Gram negative bacteria escherichia coli
RISK FACTORS:
PREDISPOSING PRECIPITATING
 Pregnancy
 Urinary tract infection  Age (15 years old)
 Urinary retention  Gender (female)
Growing uterus due to pregnancy causemechanical Compression of the bladder

compression on the ureters
Attachment of bacteria to the

Urethra Urinary Tract Infection Urinary stasis
Vesicoureteral Reflux congenital

Proliferation of bacteria in Urethritis condition where urine flow back
the Urethra
ward from the bladder
Proliferation of bacteria in Introduction of bacteria into the bladder Introduction of bacteria to the ureter
the bladder
Inflammation of the bladder cystitis ureteritis
Acute pyelonephritis Infection ascends to the kidneys
Activation of the immune General feeling of being unwell Nausea/

response vomiting
Release of Pyrogens from malaise Dysuria

bacteria
Release of prostaglandin E2 Flank pain
Elevation of the body thermostat by the Decreased erythropoietin

production
hypothalamaus
Decrease stimulation of
vasoconstriction the bone marrows
erythropoiesis
Shivering Reduced heat loss through the skin
Decreased RBC production

chills
31
fever
NURSING CARE OF THE CLIENT WITH ACUTE PYELONEPHRITIS IN PREGNANCYanemia
Preterm labor
Plans for Nursing Actions
A. Course in the Ward
Day 0 (December 3,2019)
Patient XX, 15 years old female [ G1P-0] was been admitted at Ospital ng
Lungsod ng San Jose Belmonte Bulacan at exactly 1:10 in the afternoon accompanied
by her auntie with a chief complain of pain in RLQ with 3 days of fever. She was
admitted to OB ward under the service of Dr. Y.
Vital signs of the patient were monitored every 1 hours; the patient is in 1 cm
(I.E). the patient has been under complete bed rest and monitoring every shift.
Laboratory test were ordered for patient such as Complete Blood Count with Platelet
Count and U&E urea and electrolytes (blood test). Patient diet was tolerated.
The doctor ordered IVF of D5LR 1Liter 15 gtts/min to run every 8 hours inserted
aseptically as venoclysis with D5W 500 plus 4 amps of Isoxsuprine 10 gtts/ minutes
hooked as side drip. Give the medication Paracetamol for patient fever, inject through
intramuscular the dexamethasone as the first dose, Cefuroxine 750 mg TIV after the
negative skin test.
Day 1[December 4, 2019]

Patient XX was in bed with IV D5LR 200 cc level with IVF of D5W +
Isoxyprine at 475 cc level, no signs of bleeding and contraction. Vital signs were
monitored every 4 hours, patient XX meds was given on time, complete bed rest is
instructed to the patient.
Day 2 [December 5, 2019]

Received patient on bed ongoing IVF of D5LR with full level on SD of
D5W plus 4 amps, Isoxsuprine 700 cc level, without spotting and contraction. Patient
vital signs was recorded, complete bed rest is still advised to the patient. Input of
complete blood count and platelet count are requested.

Received patient with PNSS of 320cc plus Vitamin B complex regulate
to 120 ugtts. Isoxsuprine to consume shift 150 x HCL 10 mg 1tab TID. Cefuroxime
750 mg shift to 500 mg BID.
Received patient XX in a sitting position on the bed with IVF of PNSS of 900
cc, vital signs monitored every 1hours and recorded. Completions of laboratories are
needed.
32
Received patient on bed with MGH order, discharged order are given, negative in
bleeding and negative contraction, oral medication is instructed vital signs are taken.
Received patient on bed with MGH order, Patient guardian is advised to
settle the bill, ready to discharge.
33
MECHANISM ADVERSE NURSING
DRUGS INDICATION CONTRAINDICATION INTERACTIONS
OF ACTION EFFECT CONSIDERATION
Drug Name: Inhibits cell-wall For serious Contraindicated in No adverse Drug to drug:  Monitor patient
synthesis, lower patient’s hypersensitivity effect seen on for signs and
Cefuroxime to drug. patient No drug to drug
promoting respiratory tract interaction seen in the symptoms of
Dosage/ Route: patient.
osmotic infections, UTI, superinfection
750 mg TIV instability; usually skin or ski- Drug to food: and diarrhea.
bactericidal structure
q8 6am -2pm 10pm There’s no drug to
(5ml) from Dec 3-5, infections.  Monitor renal
food interactions
2019 ANST Dec 6, observed in the patient function during
2019 (3mL) 4am
therapy,
Pharmacokinetics:
Classification: Absorption: especially when
Cefuroxime sodium maximum dose
Antibiotic
isn’t well absorbed is used in a
Clinical from the GI tract and
must be given severely ill
Significance:
parenterally. patient.
Used to treat acute Cefuroxime axetil is
infections better absorbed orally;
between 37% and  Drug may
Date Ordered: 52% of an oral dose is increase INR and
absorbed. Food
Dec 3, 2019 at 12:45 risk of bleeding.
appears to enhance
am
absorption. Monitor patient.
Due: Distribution:
Distributed widely
Dec 3 – 5 2019 into most body tissues
(5mL) and fluids, including
the gallbladder, liver,
Dec 6, 2019 (3mL) kidneys, bone, bile,
and pleural and
34
synovial fluids;
Cefuroxime crosses
the placental barrier
and is 33% to 50%
protein-bound.
Metabolism: Not
metabolized.
Excretion: Primarily
excreted in urine by
renal tubular secretion
and glomerular
filtration; elimination
half-life is 1 to 2 hours
in patients with
normal renal function;
end-stage renal
disease prolongs half-
life 15 to 22 hours.
Some drug appears in
breast milk.
Hemodialysis removes
cefuroxime.
35
MECHANISM ADVERSE NURSING
OF ACTION EFFECT CONSIDERATION
Drug Name: Unclear. Use to treat Contraindicated in No adverse Drug to drug:  Monitor patients’
Decreases inflammatory patients hypersensitive to effect seen of weight, BP and
Dexamethasone condition and drug or its ingredients. patient There is no drug to
inflammation, drug interaction seen electrolyte
shock. Used to
Dosage/ Route: of patient
mainly by accelerates levels.
6 mg IM (ANST) 4 stabilizing maturation of  Watch for
Drug to food:
doses q12 7am-7pm fetal lungs,
leukocyte depression or
decrease There’s no drug to
Classification: lysosomal number of psychotic
food interactions
membranes; neonates with observed in the patient episodes,
Corticosteroids respiratory
suppresses especially in high
distress Pharmacokinetics:
Clinical immune response; dose therapy.
syndrome and
Significance: Absorption: After
stimulates bone improves  Determine
survival in oral use, drug is
is used to treat marrow; and whether patient is
preterm absorbed readily. The
conditions such as
influences protein, delivered suspension for sensitive to other
arthritis,
fat and neonates. injection has a corticosteroids.
blood/hormone/imm
variable onset and
une system carbohydrate
duration of action,
disorders, allergic metabolism. depending on whether
reactions, certain
it’s injected into an
skin and eye
intra-articular space, a
conditions,
muscle, or the blood
breathing problems,
supply to the muscle.
certain bowel. It
After I.V. injection,
disorders, and
dexamethasone is
certain cancers.
rapidly and
Also Date
completely absorbed
Ordered:
into the tissues.
Dec 3,2019 Distribution:
Removed rapidly from
36
blood and distributed
to muscle, liver, skin,
intestines, and
kidneys.
Dexamethasone is
bound weakly to
plasma proteins
(transcortin and
albumin).
Adrenocorticoids
appear in breast milk
and the placenta.
Metabolism:
Metabolized in the
liver to inactive
glucuronide and
sulfate metabolites.
Excretion: Inactive
metabolites and small
amounts of
unmetabolized drug
are excreted by the
kidneys. Insignificant
quantities are also
excreted in feces;
biologic half-life is 36
to 54 hours.
37
MECHANISM OF ADVERSE NURSING
ACTION EFFECT CONSIDERATION
Drug Name: Chemically similar  Peripheral Recent arterial No adverse Drug to drug:  Assess patient’s
to sympathomimetic and cerebral hemorrhage, heart disease, effect seen of condition before
Isosuxprine vascular severe anemia patient There is no drug to
amines and often drug interaction seen therapy. Assess
insufficiency
Dosage/ Route: of patient
described as beta with spastic potential
10gtts/min IV adrenergic agonist. component benefits
Should not be Drug to food:
showing
However, the drug administered immediately (reduction of
10mg 4amps side symptoms: There’s no drug to
appears to be a postpartum and premature symptoms,
drip  Di food interactions
labor.
musculotropic zzi observed in the patient improved
Classification: nes
vasodilator and its Avoid parenteral emotional and
s administration to patients Pharmacokinetics:
Clinical effects are not physical
 Forgetfulne with hypotension,
Significance: Absorption: well
blocked by ss tachycardia, premature condition and an
 Co observed from the
is used in humans propranolol detachment of placenta or improved
nfu gastrointestinal tract.
for treatment of immediate post-partum
At 1 hour following prognosis for
premature labor, sio
n oral administration, extended life
i.e. a tocolytic,
Visual, auditory isoxsuprine was found
and as a expectancy)
and speech in decreasing amounts
vasodilator for the from drug
abnormaliti in the kidney, heart,
treatment of
es liver, skeletal muscle, therapy
cerebral vascular
 Coldness and brain,
insufficiency,  Monitor for
and respectively.
possible drug
Date Ordered: numbness
Distribution: free induced adverse
of limbs
Dec 3,2019 drug proved to be 2.5
 Color reactions.
times higher than that
changes  Hypotension
Due: of total isoxsuprine,
and
which indicates a  Tachycar
Dec 3 – 5 2019 ischemic
good penetration of
ulcers dia
the free drug into
 Raynaud  Nausea
tissue compartments.
38
disease Metabolism: Not  Vomiting
metabolized  Dizziness
 Uterine
Excretion: half-lives  Severe rash
hypermotili
ty disorders of 14 minutes and  Inform the patient
 Threatened 2.67 hours
about possible
abortion
side effects,
adverse symptoms
to report.
39
MECHANISM OF ADVERSE NURSING
ACTION EFFECT CONSIDERATION
Drug Name: Produces analgesia Mild pain or Hypersensitivity to No adverse Drug to drug: There  Monitor for S&S
by unknown fever acetaminophen or effect seen of is no drug to drug of: hepatotoxicity
Acetaminophen phenacetin; use with patient interaction seen of
(Paracetamol) mechanism, perhaps (rash, stomach,
alcohol. patient
by action on nausea and
Dosage/ Route: Drug to food:
peripheral nervous vomiting,
1amp(300 mg) system. Reduces There’s no drug to fatigue, dark
q4 for fever food interactions
fever by direct colored urine,
observed in the patient
Classification: action on light-colored
hypothalamus heat- Pharmacokinetics: bowel
Analgesic
regulating center Absorption: Rapid movement,
Clinical
with consequent and almost complete jaundice loss of
Significance:
peripheral absorption from GI appetite), even
used to treat pain tract; less complete
vasodilation, absorption from rectal with moderate
and fever. It is
typically used for sweating, and suppository. Peak: acetaminophen
mild to moderate dissipation of heat. 0.5–2 h. Duration: 3–4 doses, especially
pain relief. h.
Unlike aspirin, in individuals
Date Ordered: acetaminophen has Distribution: Well with poor
distributed in all body
little effect on nutrition or who
Dec 3, 2019 at fluids; crosses
12:35 am platelet aggregation, placenta. have ingested
does not affect alcohol over
Metabolism:
bleeding time, and prolonged
Extensively
generally produces metabolized in liver. periods;
no gastric bleeding. poisoning,
Elimination: 90–
100% of drug excreted usually from
as metabolites in accidental
40
urine; excreted in ingestion or
breast milk. Half-Life: suicide attempts;
1–3 h.
potential abuse
. from
psychological
dependence
(withdrawal has
been associated
with restless and
excited
responses).
41
NURSING
MECHANISM OF CONTRAINDICA ADVERSE
DRUGS INDICATION INTERACTIONS CONSIDERATIO
ACTION TION EFFECT
N
Drug Name: Ferrous Sulfate is an The prevention or Patients receiving No adverse effect Drug to drug:  Monitor serum
essential component treatment of iron repeated blood seen of patient iron, total iron-
Ferrous Sulfate deficiency anemia transfusions; anemia There is no drug to binding
in the formation of drug interaction
due to inadequate not due to iron capacity,
Dosage/ Route: seen of patient
hemoglobin, diet, malabsorption deficiency. reticulocyte
600 mg myoglobin and pregnancy, and count,
Drug to food:
blood loss. hemoglobin,
enzymes. It is
Frequency: There’s no drug to and ferritin.
necessary for  Monitor daily
food interactions
Once a day (6am) effective pattern of
observed in the
patient bowel activity
Route: erythropoiesis and
and stool
transport or Pharmacokinetics: consistency.
PO
utilization of Absorption:  Assess for
Classification: oxygen. Absorbed from the clinical
entire length of the improvement,
Enzymatic mineral GI tract, but primary record of relief
and Iron absorption sites are of symptoms
preparation. the duodenum and (fatigue,
proximal jejunum. irritability,
Clinical
Up to 10% of iron is pallor,
Significance:
absorbed by healthy paresthesia,
individuals; patients and headache).
used to treat iron
with iron-deficiency
deficiency anemia
(a lack of red blood anemia may absorb
cells caused by up to 60%. Enteric
having too little iron coating and some
in the body). extended-release
formulas have
Date Ordered: decreased
absorption because
42
Dec 7, 2019 they’re designed to
release iron past the
points of highest
absorption; food
may decrease
absorption by 33%
to 50%.
Distribution:
Transported through
GI mucosal cells
directly into the
blood, where it’s
immediately bound
to a carrier protein,
transferrin, and
transported to the
bone marrow for
incorporation into
hemoglobin. Iron is
highly protein-
bound.
Metabolism:
Liberated by the
destruction of
hemoglobin but is
conserved and
reused by the body.
Excretion: Healthy
people lose very
little iron each day.
Men and
postmenopausal
women lose about 1
mg/day, and
premenopausal
43
women about 1.5
mg/day. The loss
usually occurs in
nails, hair, feces,
and urine; trace
amounts are lost in
bile and sweat.
44
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Hyperthermia 1. Rectal and GOAL MET
related to infection tympanic
Pyrogens cause a LONG TERM INDEPENDENT
“Bigla pong in the urinary tract After 1 week of
as evidenced by rise in body GOALS: 1. Monitor vital signs temperature most
sumakit yung increase in body nursing
closely
temperature; it After 1 week of and core
tagiliran ng tiyan ko temperature greater approximate core interventions;
than normal, flushed also acts as an nursing temperature by
tapos nilalagnat din skin and warm to temperature
antigen interventions; appropriate route.  The client is
ako kaya po touch Doenges, Marilynn
triggering  The client free from
nagpacheck- up E.,, Moorhouse,
immune system will be free 2. Discuss the infection in the
agad ako”, as Mary
responses. The from importance of urinary tract as
verbalized by the Frances,Murr,
hypothalamus infection in adequate fluid evidenced by
Alice C..
patient.
reacts to raise the the urinary intake. (©2013) Nurse's the absence of
set point and the tract. pocket guide fever, chills,

3. Promote surface :diagnoses, and flank pain.
OBJECTIVE: body responds by  The client
cooling by means prioritized  The client
producing heat. will be able
 Flushed skin of cool or tepid interventions, and verbalized the
to verbalize
and weakness sponge baths. rationales Philadel proper ways to
Potter, P. A., the proper
observed Perry, A. G., phia, PA : F.A.
ways to prevent the
Hall, A., & DEPENDENT Davis Co., pg. 428
 Warm to touch reoccurring of
Stockert, P. A. prevent the 4. Administer 2. To prevent
 RLQ pain (2017). Fundam the infection.
entals of reoccurring Paracetamol 1amp dehydration.
 Vital Signs: nursing. Ninth of the TIV and Doenges, Marilynn
edition. St. Louis,
Temperature: 37.8 Mo.: Mosby infection. Cefuroxime 750mg E.,, Moorhouse,
After 4 hrs of
45
°c Elsevier. TIV for infection Mary effective nursing
SHORT TERM as ordered by the Frances,Murr, intervention;
Blood Pressure: Alice C..
GOAL: physician.
(©2013) Nurse's
 The client’s
110/70 After 4 hrs of
pocket guide temperature
nursing 5. Maintain complete
:diagnoses, returned within
intervention the bed rest.
prioritized normal range
client’s
interventions, and and the pain is
6. Laboratory tests
temperature will rationales Philadel
such as CBC test, lessened.
decreased and phia, PA : F.A.
UA, and UTZ.  Skin is cool
pain will be Davis Co., pg. 428
and absence of
lessened as 3. To promote heat
COLLABORATIVE flushing.
evidenced by; loss by evaporation
7. Refer to
 Demonstrate and conduction. The patient
dietician for
Doenges, Marilynn together with her
temperature significant others
counseling
E.,, Moorhouse,
within understand the
to Mary cause of disease
normal and are ready to
individual Frances,Murr,
levels practice specific
dietary Alice C.. interventions to
 Skin is cool plan, (©2013) Nurse's prevent
to touch and hyperthermia.
specifically pocket guide
less a low fat :diagnoses,
flushness. and low prioritized
 Verbalize interventions, and
sodium
understandin rationales Philadel
46
g of specific diet. phia, PA : F.A.
interventions Davis Co., pg. 431
to prevent 4. Paracetamol is used

for mild pain and
hyperthermi
fever. (pg. 66)
a.
Cefuroxime is
mainly used as an
antibiotic for
urinary tract
infections.
5. To reduce
metabolic demands
and oxygen
consumption.
Doenges, Marilynn
E.,, Moorhouse,
Mary
Frances,Murr,
Alice C..
(©2013) Nurse's
pocket guide
:diagnoses,
prioritized
interventions, and
47
rationales Philadel
phia, PA : F.A.
Davis Co., pg. 430
6. Increased WBC
count is a systemic
response to
infection. The
presence of RBCs
and WBCs in the
urine is associated
with the
inflammation
process during an
infection.
48
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SHORT TERM: INDEPENDENT 1.To get more The goal was met:
SUBJECTIVE: ACUTE PAIN After 4 hrs.of 1.Established rapport. information and As evidence by
“Sobrang sakit ng related to acute nursing 2.Monitor maternal gain a trust. decrease of pain
tagiliran ko tapos inflammation of intervention the and fetal vital sign. 2.Vital sign of client scale from 8/10 to
natakot na rin ako renal tissues as client report 3.Assess pain and fetus may be 2/10
lalo na buntis ako secondary to uterine decreased of pain characteristic: Quality, altered by anxiety
kaya dinala na ako contraction. and controlled. onset/duration, level. -verbalize by the
ng asawa ko sa frequency, severity, 3.Be able to client that she fee
ospital”.as LONG TERM: intensity. compare change better
verbalized by the After 8hrs.of 4.Assess for referred from previous
patient. nursing pain, as appropriate. report to rule out
intervention the 5.Observe non-verbal worsening
OBJECTIVE: client cues and pain behavior underlying
G2P0 verbalize”she and other objective condition
-(+)facial grimace feel better”. defining as noted. developing
Pain scale 8/10 6.Provide comfort complications.
Temp 37.5 measure. 4.to help determine
BP 110/70 -(-) facial 7.Encourage the possibility of
PR 100 grimace and verbalization of feeling underlying
IE 1cm guarding about the pain. condition or organ
behavior 8.Encourage dysfunction
diversional activities requiring treatment.
and relaxation 5.Observation may
technique. not congruent w/
9.Encourage adequate verbal report or may
rest period. be only indicator
DEPENDENT: present when client
-Administer analgesic is unable to
as necessary. verbalize
-Cefuroxime 750 mg (NANDA 13TH
TIV EDITION Pg660)
-Dexamethasone 6mg 6.To promote
49
IM pharmacological
-Isosuxprine 40mg IV pain management
-Paracetamol 1amp (NANDA 13TH
TIV EDITION Pg.661)
-Complete bedrest 7.to evaluate
-CBC test copping abilities
-UA test and to identify areas
-UTZ test of additional
-dailky perineal concern.
hygiene (NANDA 13TH
EDITION Pg.661)
COLLABORATIVE: 8.to distract the
-Administer attention and reduce
medication as of level of anxiety,
indicated.eg analgesic fear and also
antibiotic. tension.
-with the dietician (NANDA 13TH
prescribe such as: EDITION Pg.661)
 Low fat intake 9.to prevent fatigue
 Low sodium that can impair
intake ability to manage or
-Lab test: cope w/ pain.
o CBC test (NANDA 13TH
o UA test EDITION Pg.662)
o UTZ test
50
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
Subjective: Acute Pain related Short Term: Independent:  After 4 hours of

1.To gain trust
to infection within nursing
“Sumasakit yung the urinary tract  After 4 hours of 1. Establish and get more
intervention,
tagiliran ng tiyan secondary to uterine nursing Rapport information
the patient’s
ko” as verbalized by contraction interventions, Which are pain are
the patient. the patient’s 2. Monitor Skin usually altered relieved and
pain will be color,
temperature and in acute pain controlled
relieved or
controlled vital signs (e.g.,  After 6 hours of
Objective: heart rate, nursing
 Patient received  After 6 hours of blood pressure, 2.To promote intervention,
sitting on bed nursing respiration) nonpharmacolo the patient
intervention, -gical pain knowledge
 Facial grimace the patient will 3. Provide management increase about
be able to comfort
 Weak and Pale measures (e.g., the preventive
looking increase the measures and
knowledge of Touch,
repositioning, treatment
 Fever preventive modalities
measure and use of heat or 3.To distract
treatment cold packs, attention and
modalities. nurse’s reduce tension
Measurement:
presence), quiet
BP - 110/70 environment,
and calm
Temp. - 37.8 Long Term: activities
Pulse Rate - 100  After 1 week of 4. Instruct in and
nursing encourage use
IE - 1cm intervention, of relaxation
the client will techniques,
51
be free from such as focused
urinary tract breathing,
infection. imaging,
CDs/tapes (e.g.,
“White” noise,
music, 4.To maintain
instructional) “acceptable”
level of pain.
5. Administer Notify
analgesics, as physician if
indicated, to regimen is
maximum inadequate to
dosge, as meet pain
needed. control goal.
6. Encourage Combination of
adequate rest medication may
period. be used on
prescribed
Dependent: intervals.
Administer 5.To prevent
medication: fatigue that can
impaire ability
 Cefuroxime to manage or
750mg TIV cope with pain
 Dexamethasone
6mg IM
 Isosuxprine
40mg IV
 Paraxetamol
1amp TIV
 Complete bed
52
rest
 CBC Test
 UA Test
 UTZ Test
Collaborative:
 Administer
medication as
indicated (e.g,
analgesics)
 With the
dietician
prescribed such
as:
- Low fat intake
- Low sodium
intake
 Lab test:
- CBC test
- UA test
- UTZ test
53
C. Discharge Plan
Client with acute pyelonephritis is instructed to take the following plan for discharge.
M-edication should be taken regularly as prescribed like cefuroxime 500mg/tab 2x a day (6am
and 6pm) in 3 days, Isosuxprime 10mg/tab 3x a day (6am,2pm,10pm) in 7 days, Multivitamins
and ferrous sulfate 600mg/cap should be taken in the morning (6 am) on exact dosage, time and
frequency. The treatment regimen ordered by the doctor must be followed strictly.
E-xercise should be promoted in a way.Making sure that the patient will have a safe and slouchy
bed to rest. Advise the family to avoid exposing the patient in doing heavy work or Activity.
Instruct the guardian on ways how to maintain the cleanliness of environment for the client.
T-reatment after discharge is expected. Instruct the patient to take her prescribed medicine at the
proper dosage, frequency, route of administration and at the right time. Inform the patient to have
a regular follow up check up December 19,2019
H-ealth teaching about the importance of keeping 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.
Encourage the patient to drink more fluid six to eight glasses a day this promote frequent
urination and flushed bacteria from the bladder. Inform the patientthe patient for doing
handwashingafter urinate and Avoid delaying of urination when it is necessary.
O-ut patient consultation such as regular follow up check up after 1 week of discharge as ordered
by the physician to evaluate condition of the client. Instruct the patient to seek or return upon
experience if any sign and symptoms such as severe abdominal pain, fever, painful urination.
D-iet for patient who has an Acute pyelonephritis are eating nutritious food like green leafy
vegetables such as malunggay,kangkong,etc.and liver.Increasing oral fluid intake is important.
Avoid salty foods such as cup noodles,junk foods,processed food and soft drinks.
S-piritual activities like praying and attending church activity can help improve the patient’s
condition.Encourage the patient to enjoy company with family,friends,and relati
54
Reference:
https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/obstetrics-and-gynecology/acute-
pyelonephritis-in-pregnancy/
https://www.webmd.com/baby/guide/anemia-in-pregnancy
https://www.scribd.com/doc/11935739/NursingCrib-com-Nursing-Care-Plan-Urinary-Tract-Infection-UTI
https://nurseslabs.com/urinary-tract-infection/
https://www.webmd.com/baby/guide/anemia-in-pregnancy
https://www.emedicinehealth.com/hematocrit_blood_test/article_em.htm
Nursing 2019 Drug Handbook pg. 312 -cefuroxime
Nursing 2019 Drug Handbook pg. 430 -dexamethasone
Nursing 2019 Drug Handbook pg. 66 -acetaminophen(paracetamol)
https://www.scribd.com/doc/31650109/Isoxsuprine
https://www.drugs.com/ferrous_sulfate.html
Janeth R. Weber, RN, EdD, Jane H. Kelley, RN, PHD Sixth Edition Health Assessment. 250-407
https://www.webmd.com/kidney-stones/picture-of-the-kidneys#1
55
56
57

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VISION MISSION

A premier inclusive university of The Our Lady of Fatima

2nd Semester AY: 2019-2020

NURSING CARE OF THE CLIENT WITH ACUTE PYELONEPHRITIS IN

A Case Study Presented to the Faculty

In Partial Fulfillment of the Requirement in NCM 219 OB for the Degree,

General objectives ..…………….………..………………………………….4

Chapter 2: REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY

Chapter 3: RESULTS DISCUSSION: ANALYSIS AND INTERPRETATION

I. Comprehensive Physical Examination……………………………………………..……….21

Chapter 4: SYNTHESIZING FRAMEWORKS, INFERENCE,ACTION PLANS AND

II. Back ground of the Study

Acute Pyelonephritis is a bacterial infection causing inflammation of the kidneys

Purpose of the Study

A. Initials of Clients’ Name XX

B. Address Citrus, QC3 Bulacan City

C. Age 15 years old

D. Birth date February 19, 2004

E. Birth Place Ospital ng San Jose Del Monte

G. Civil Status Single

I. Highest Educational Attainment Grade 8

K. Monthly Income/ Budget None

L. Date of Admission December 3, 2019 (Tuesday)

M. Date of Interview December 4, 2019 (Wednesday)

N. Primary Informant Patient XX

O. Secondary Informant Mother-in-Law/ Grandmother

P. Other data sources Patient’s chart

II. REASON FOR SEEKING HEALTH CARE

IV. PAST MEDICAL HISTORY

Evaluation Questions Almost Some of the Hardly

0-3 = Low 4-7 = Moderate 8-10 = High

VI: SOCIO-ECONOMIC HISTORY

VII: DEVELOPMENTAL HISTORY

A. Erick Erikson’s psychosocial Development

-The patient mentioned that she is

B. L.Kholberg’s moral development

VIII.Gordon’s 11 Functional health Management

before hospitalization During hospitalization

 She drink alcoholic beverages

Before hospitalization During hospitalization

Before hospitalization During hospitalization

Before hospitalization During hospitalization

*Katz Index of Independence in Activities of Daily Living During

Activities Independence=1 point Dependence-0 point

Points (1 or 0) No supervision,direction or With supervision,direction or

Before hospitalization During hospitalization

Before hospitalization During hospitalization

Before hospitalization During hospitalization

Before hospitalization During hospitalization

Before hospitalization During hospitalization

The patient menstrual cycle is regular until pregnancy started

Before hospitalization During hospitalization

K. Value Belief pattern

Before hospitalization During hospitalization

Chapter 3: EVALUATION RESULTS INTERPRETATION, ANALYSIS,

I. Comprehensive Physical Examination

Normal Finding Actual Finding Clinical

Skin Evenly colored Skin tone is

Normal breath soun Patient’s breath

ABDOMEN Abdominal skin Abdomen doesn’t NORMAL

NEUROLOGIC Client is alert and Client is alert and NORMAL

HEMATOLOGY RESULT December 03, 2019

Lymphocytes 0.25-0.35 0.19 Abnormally Lymphocyte counts