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A Clinical Case Study Presented to Tarlac State University College of Nursing Lucinda Campus, Brgy.

Ungot, Tarlac City Philippines 2300

In partial fulfillment on the requirements in the subject NCM 107 (RLE)

Acute Pyelonephritis

Presented by: Bagsic, Brandon L. Balibat, Rudolf John L. Dayao, Precious Mariz M. De Celis, Joy M. Fernando, Fleur Rossellini R. Gonzales, Juvi Ann A. Llarves, Marjorie E. Naigan, Lee Mica C.

Presented to:

TABLE OF CONTENTS

I. II.

III. IV. V. VI.

Introduction....1 Nursing Process a) Assessment 1. Personal Data.4 2. Family History of Health and Illness...6 3. History of Past Illness7 4. History of Present Illness..7 5. Physical Assessment (13 Areas)...7 6. Laboratory and Diagnostic Procedures.17 7. Anatomy and Physiology.19 8. Pathophysiology...23 b) Planning 1. Nursing Care Plans..27 c) Implementation 1. Drugs. 2. Surgical Management. 3. Medical Management 4. Diet 5. Activity/Exercise. 6. Nursing Management.. d) Evaluation 1. General condition upon discharge 2. METHOD.. Conclusion.. Recommendation Review of Related Literature. Bibliography

I. INTRODUCTION

Pyelonephritis is an inflammation of renal pelvis and parenchyma caused by bacterial infection. The caused may be an active infection on the kidney or the remnants of previous infections. Acute pyelonephritis often occurs after bacterial contamination of the urethra or after introduction of an instrument such as a catheter or a cystoscope. It is characterized by enlarged kidneys, focal parenchymal abscess and accumulation of polymorphonuclear lymphocytes around and in the renal tubules. Assessment usually reveals high fever, chills, nausea, and flank pain on the affected side (costovertebral angle [CVA] tenderness), headache, muscle pain and general prostration. The pain commonly radiates down the ureter or toward the epigastrium and may be colicky if the infection is complicated by calculiar sloughed renal papillae. Commonly the client experiences dysuria, frequency and urgency for several days. Urine maybe cloudy or bloody foul smells and shows marked increase in WBCs and casts. (Black, J. and Hawks, J., Medical Surgical Nursing 8th Edition). All cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment. Mild cases can be treated with oral therapy but generally intravenous antibiotics are required for initial stages of treatment (Wikipedia.com). About 1 out of 7,000 people develop pyelonephritis in the United States (Retrieved from Stephen J., et al freemd.com, 2008). About 310 deaths reported in the Philippines due to pyelonephritis (emedicine.com, 2002). TPH?

Reason for Choosing this Case Study Acute pyelonephritis really captures the researchers interest among the other cases of the confined patients. The researchers are eager to study about the disease due to the curiosity towards the condition of the patient which gave us questions just like how does the disease affect an individual in different aspects; physically, emotionally, and socially and somehow to help the patient promote and restore wellness by providing the patients needs and knowing the nursing responsibilities when caring for the patient. It is an opportunity for the researchers to study the disease to equip their knowledge and skills to be able to manage future patients with the same disease in providing a quality nursing care.

Importance of the Case Study This case study is intended to educate, inform and change untoward behaviors regarding the disease- acute pyelonephritis. This case study will help the patient to recover faster and maintain holistic sense of wellness through applied effective management of the problem experienced by the patient and it can also lessen the functional burden of the patient by understanding the treatment process and able to cope and adapt in the present condition and also the patient will be able to know the importance of taking care of his own self. This case study can also help the researchers to gain new information about the disease and its etiology, pathophysiology, clinical manifestations as well as the standard medical and nursing management so that we may apply this newly-acquired knowledge to our patient as well as in similar situations in the future. The researchers will learn new clinical skills as well as sharpen their current clinical skills required in the management of a patient with acute pyelonephritis.

Objectives General Objectives:  To have a better understanding of the course of the disease, its causes, signs and symptoms, diagnoses & treatment. Specific Objectives: Nurse-centered After doing this case, the group will be able to:  Institute methodical nursing procedures that will help the researchers to familiarize specific actions in giving care to the patient.  Have a better understanding of the specific things that can be seen with clients having this certain condition.  Assess the patient using the assessment techniques and obtain significant data related to the patients condition.  Identify and analyze problems based from the gathered pertinent data to come up with appropriate nursing diagnoses.  Plan and implement appropriate nursing interventions to improve the patients condition not only physically but as well as mentally, socially and emotionally.  Evaluate the effectiveness of the nursing interventions rendered and note the significant progress of the patient. Client - centered After doing this case, the patient will be able to:  Discuss the indications and management of the client with acute pyelonephritis.  Encouraged cooperation to the health process  Provide client education and involve patient in implementing therapeutic regimen to promote understanding and compliance  Describe the nursing care for the client with acute pyelonephritis  To comply with the health teachings provided during hospital confinement.

II. NURSING PROCESS a. ASSESSMENT i. Personal Data 2. Demographic Data Name: Mr. X Age: 65 y/o Sex: Male Civil Status: Married Religion: Roman Catholic Role in the Family: Head of the family Nationality: Filipino Usual Source of Health: Phil Health Chief Complaint: Flank pain and calf pain Admitting Diagnosis: Acute Pyelonephritits Date of Admission: January 5, 2012 Final Diagnosis: Acute Pyelonephritis 3. Environmental Status According to the patient, their house is made of concrete and is divided into a bedroom, a living room, and kitchen. He verbalized that each room of their house is kept well ventilated by the windows found in each room. Their main source of water is a deep well. They have different ornamental plants in their yard like santan, and gumamela. They have two dogs and one cat that stay outside as verbalized by the patient. He also said that their toilet was build outside their house which drains to a closed drainage system. Motorcycles and tractors are their main source of transportation. They communicated each other using their cellphones. Their house is situated ten meters from the road and 500 meters from the health center.

4. Lifestyle Mr. X wakes up each morning at round 5 am. He usually starts the day with a coffee and sticks of cigarettes; he usually smokes 1 pack of cigarettes and then prepares for his work on the farm. He usually eat his lunch at 12noon, he usually spent the day working in the farm. Their family eats three meals a day, commonly composed of vegetables, meat and fish. According to him, his favorite dish was pinakbet. He is also fond of seasonings like soy sauce and fish sauce whenever he eats. He only drinks 3-4 glasses of water per day, according to him. The patient spends the evening watching TV and sleeps at 9 in the evening. Their main source of income is their farm.

i. Family History of Health and Illness

Paternal UA 90 HPN UA

Maternal UA 75 HA UA

65 UC

63 UC

72 A&W

65 A&W

63 A&W

55 PYE

61 A&W

Legends:
UA HPNMale Female Deceased Unknown Age Hypertension UC- Unknown Caused A&W- Alive& Well - Pertains to patient PYE- Pyelonephritis

HA - Heart Attack

ii. History of Past Illness According to Mr. X, he experienced illnesses like chicken pox and mumps during his childhood. Sometimes he also experiences fever, cough and colds which he treats taking overthe-counter drugs such as biogesic, neozep, and solmux. He had noted that he does not have any allergies to foods, drugs and environmental factors. According to him, he had completed his childhood immunizations. He experienced UTI when he was on 40 years of age. He claims that he had not been hospitalized before and that this present hospitalization was his first time.

iii. History of Present Illness Few weeks prior to admission, the patient had experienced a low-grade on and off fever accompanied with flank pain which he treated by taking alaxan and paracetamol which afforded him slight relief. Three days prior to admission the patient had on and off fever associated with flank pain and calf pain. There was no vomiting noted. Mr. X self medicated with paracetamol 500 mg TID which afforded him slight relief. Persistence of the above mentioned symptoms prompted consult, hence admitted.

13 Areas of Assessment 1. Social Status Mr. X is 65years of age and was the youngest among the six children of his parents. He claimed that he is a Roman Catholic. When he was asked about his educational attainment, he said that he was a high school undergraduate. Before he was hospitalized he said that he used to have conversation with his family during meal times and the topic of their conversation is usually the things that had happened in their lives, and most of his free time is mostly consumed by watching TV. He verbalized that he has a good relationship with his relatives and family members. During the interview with the patient, the researchers observed that despite of his condition he was still able to entertain and answer some of our questions. According to him he talks with his nephew when he is bored. The researchers also observed that his relatives and family members took charge in watching him while he was confined to the hospital. Norms: Family members should help one another by doing their responsibilities in the family. Good communication within the family must be maintained to obtain a healthy relationship with one another. Social support is a perception that one has an emotional and tangible resource to call on when needed. Perceived social support is being followed by the family to express the love and care to each one of them (Kozier, 2004).

Analysis: Based from the observations, it shows that during his hospitalization, he found that talking with his significant others is his way of relieving his boredom. When he was hospitalized, his family and relatives are concerned about his situation.

2. Mental Status a. General Appearance and Behavior During the interview Mr. X is on a sitting position. He looks weak. He wears appropriate clothing with regards to his age, socioeconomic status and weather. He has poor hygiene as

manifested by uncombed hair, soiled clothing, untrimmed dirty nails, and body odor. He also has facial grimace and irritable at times due to the felt pain in the pelvic area.

b. Level of Consciousness Mr. X was drowsy but responsive during the interview. He cooperated well throughout the assessment. He responds to questions being asked spontaneously and relatively.

c. Intellectual Functioning Mr. X was able to understand every question that was asked from him and he was able to respond to them appropriately. Long term memory is functioning well and he was able to narrate past events in his life. Short term memory was also functioning well. He was also able to narrate recent events in his life. Facial expressions are congruent with the context of the conversation.

d. Orientation Mr. X was oriented about his condition and stay in the hospital, he was able to state the right time, place, and date of the day. e. Speech The patient was able to read and write. His spoken words were clearly understood. He can speak languages like Tagalog and Kapampangan. Norms: The client should be reason, to find meaning, and make judgement from information, to demonstrate rational thinking and perceive realistically. Appearance and behavior; posture must be relaxed. Client should be dressed appropriately with the season, age, and gender. Grooming and hygiene should be proper and neat. Clients should typically be able to state their name, location, date, month, season, and time of the day (Estes, 2006).

ANALYSIS: His behavior, speech, cognitive ability, and memory are normal. Drowsiness is caused by lack of sleep. Irritability and facial grimace is due to pain.

3. Emotional Status Mr. X said that money matters are their number one problem. He said that he and his wife talk with each other and think of the possible ways of solving their problem. Regarding to their other dilemmas, he said that they asked help from God and relative when they think they cannot handle the problem by their own.

Norms: A persons emotional status depends much on his ability to cope up with the happenings in his life. He may or may not be emotionally stable of unfortunate incidents happened (retrieved from www.nursingceu.com).

ANALYSIS: The patient was able to asked help to other people as his coping mechanism when he feels that he cannot handle a certain problem.

4. Sensory Perception a. Sense of taste Tongue is pinkish in color and moist. The patient was able to perform normal tongue movements when asked to move his tongue from side to side and up and down. The patient can differentiate the taste of the foods he eats. He has an incomplete number of teeth.

Norms: The tongue should be in the midline of the mouth, the dorsum of the mouth must be pink, moist, and rough, and must be free from lesions. It should move freely and the strength of the tongue is symmetrically strong. The number of teeth should be complete and no visible dental caries. A person has no problem about his sense of taste if he can identify the sweet, sour, salty, and bitter taste of foods he eats (Estes, 2006).

ANALYSIS: The patients sense of taste is normal, for he was able to identify different kinds of taste. Incomplete number of teeth (30 teeth) is due to dental caries.

b. Auditory Activity Hearing test was performed in the patient to check if he has a good auditory acuity. One of the members of the group whispered words (ano po pangalan nyo) 3 inches away from him; he was able to repeat the words correctly and clearly as the asked him to repeat it.

Norms: Patient should hear whispered words and ears must be free from lesions and masses (Estes, 2006).

ANALYSIS: The patients auditory sense has no problems for he was able to hear the whispered words. c. Sense of Smell Mr. X can distinguish different odors. He was able to smell the foul odor of the surrounding. His nose lies on the midline of his face and it is symmetrical. His nostrils are patent, no evidence of swelling of the frontal maxillary sinuses and excessive mucous discharges.

Norms: The patient must be able to identify different odor. The nose should be at the midline position of the face with intact nostrils and free from lesions. Nose should be patent. No evidence of swelling of sinuses. (Estes, 2006).

ANALYSIS: The patient has no problem regarding his sense of smell.

d. Sense of Sight The patient wears a reading glass to read small texts. The conjunctiva is pale and moist. The pupils are equally round, reactive to light and accommodation. The pupils are able to constrict and dilate in reaction to light.

Norms: The patient who has a visual acuity of 20/20 in a Snellen chart test is considered to have a normal visual acuity. Pupils are equally round and reactive to light and accommodation. No lesions and abnormalities must be seen (Estes, 2006).

ANALYSIS: The patient wears reading glasses to read small texts because of his old age. He also shows a pale conjunctiva.

5. Motor Stability Mr. X was observed to have an intolerable gait or movement including his posture and stature. He is unable to carry out tasks by himself and has limited body movements. This was seen during the first contact with the patient who still asked his significant other to assist him from moving. He was able to perform flexion and extension of his upper and lower extremities.

Norms: Range of Motion standards are follows: Walking is limited in one smooth, rhythmic fashion as the heel strikes the floor body weight is then shifted to the bail of the foot, and then elevates off the floor before the rest step forward. The normal ROM for the shoulder is circumduction. The normal ROM for the elbows is extension and flexion. The normal ROM of the wrist is extension, hyperextension, flexion supination and pronation. The normal ROM for the knees is flexion and extension.

The normal ROM for the ankles and feet is dorsiflexion, plantar flexion, inversion, abduction, and adduction (Estes, 2006). ANALYSIS: He has limited body movement due to the pain and discomfort he is experiencing.

6. Body Temperature The patients skin was warm to touch during the interview. The following table indicates the patients body temperature.

Date and Time January 5, 2012 7:30 pm 9:30 pm 11:00 pm January 6, 2012 7:00pm 9:00pm 11:00 pm January 7, 2012 2:00 pm 4:00 pm 6:00 pm Norms:

Temperature 38.2 C 37. 6 C 37.5 C 36.8 C 37.1 C 36.9 C 37.1 C 36.8 C 37.2 C

35.5 C to 37.5 C is the normal body temperature (Kozier, 2004).

ANALYSIS: The patients body temperature ranges from 35.8 C to 38.3 C assessed via axillary route. Comparing the findings from the norms, the patient showed significant change in his body temperature due to infection last January 5, 2012 but achieved normal body temperature after 2 hours.

7. Respiratory Status The patient breaths with ease and has a regular rhythm, he does not use accessory muscles when breathing. There were no manifestations of abnormally shaped or structure chest. Shoulder where of the same height as well as scapula with no palpated mass or lesions. His lungs are symmetrical in expansion. Upon auscultation, bronchovesicular sounds were heard throughout peripheral lung fields. His assessed respiratory rates are as follows: Date and Time Jan.05, 2012 7:30pm 9:39 pm 11:00 pm Jan.06, 2012 7:00pm 9:00pm 11:00pm Jan.07, 2012 2:00 pm 4:00 pm 6:00 pm Norms: Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern, normal respiration must be regular and even in rhythm. The normal depth of respirations must be effortless (Estes, 2006). 19 cpm 21 cpm 20 cpm 24 cpm 26 cpm 23 cpm 27 cpm 28 cpm 30 cpm Respiratory Rate

ANALYSIS: Elevated respiratory rate is due to pain the patient is experiencing. 8. Circulatory Status Upon handling Mr. L, he has a good capillary refill which returns two to three seconds. The peripheral pulses are palpable and regular in rhythm. Nail beds and palpebral conjunctiva are pink in color.

Date and Time Jan.05, 2012 7:30 pm 9:30 pm 11:00 pm Jan.06, 2012 7:00 pm 9:00 pm 11:00 pm Jan.07, 2012 2:00 pm 4:00 pm 6:00 pm

Pulse Rate 130 bpm 114 bpm 110 bpm 99 bpm 102 bpm 109 bpm 89 bpm 82 bpm 85 bpm

Blood Pressure 80/60 mm Hg 90/70 mm Hg 90/70 mm Hg 90/70 mm Hg 100/70 mm Hg 120/80 mm Hg 100/70 mm Hg 120/80 mm Hg 110/80 mm Hg

Norms: Normal pulse rate of an adult is 60-100 beats per minute. A regular pulse occurs at regular intervals with even intervals between each beat. Pulse volume can range from absent to bounding. When assessing symmetry, the pulses should be equal bilaterally. Normal blood pressure of an adult should be <120 mmHg in systolic pressure and diastolic pressure of <80 mmHg. The nails have a pink cast in light skinned individuals and are brown in dark skinned individuals. Capillary refill may vary with age, but color should return to normal within 2-3 seconds. (Estes, 2006)

BP Classification

SBP (mmHg)

DBP (mmHg) <80

Normal

<120

Prehypertension Stage1 hypertension Stage2 hypertension

120-139 140-159 >160

80-89 90-99 >100

The force of the arterial pulse

3+rapid and bounding 2+normal 1+.weak and thready 0..absent

ANALYSIS: The pulse is palpable and regular in rhythm. The palpebral conjunctiva and nail beds are pink. The pulse rate is elevated during the 2 days visit due to the pain being felt by the patient. The blood pressure showed a slight decrease from the normal range.

9. Nutritional Status Mr. X is 55 in height and weighs 58 kg. His abdominal girth is 33 inches. He doesnt have any food allergies and is not a picky eater as he verbalized. He prefers vegetables than meat as verbalized. He is fond of seasonings like soy sauce and fish sauce whenever he eats. His water intake varies with the weather, usually 4 glasses of water per day. He is hooked to PLRS 1L regulated at 20-21 gtts/min. He has an incomplete set of teeth but still can tolerate eating solid foods. BMI Computation: Given: weight = 65 kg Height = 5 ft 5 inch (1.68 m) BMI = weight in kg / height in (m)2 = 58 / 2.82 BMI Norms: BMI is a measurement that indicates body composition. The degree of overweight or obesity as well as the degree of underweight can be determined by making use of BMI (Estes, 2006). Standard Body Mass Index for Adults (Valdez, 2009) Underweight = <18.5 Normal weight = 18.5-22.9 Overweight = 23-24.9 = 20.57

Obesity = BMI of 25 or greater

ANALYSIS The patient has a normal BMI as to compare with the norms above. But his oral fluid intake is deficient.

10. Elimination Status The patient claims that he usually defecates one to two times a day, brown in color, and soft but formed. When asked if how many times he urinates a day, he said that he urinates at least 3-4 times a day (150 cc for 6 hours), dark yellow in color, turbid in transparency. He also experiences dysuria upon urination. According to him, he controls the urge to urinate. Norms: Normal bowel movement is usually 2-3 times a week which help in elimination of unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in color. Urine output of an adult is usually 1200-1500mL per day (Kozier, 2004).

ANALYSIS: The patient has regular bowel but has decreased urine output. 11. Reproductive Status The patient has 3 children. He is 65 years, married. They are no longer sexually active as he verbalized. He said that his wife did not use any contraceptives. He verbalized that he has no history of impotence and he has no sexually transmitted diseases. Norms: Physiologic factors that can affect sexual health include presence of illnesses, disabilities and sexually transmitted diseases. Medications that can alter sexual function are alcohol, antidepressants, antihistamines, antihypertensive, antispasmodics, CNS depressants, chemotherapy and oral contraceptives (Kozier, 2004).

ANALYSIS: The patient has a normal reproductive status. 12. State of Physical Rest and Comfort The patient verbalized that he usually sleeps at 9 oclock in the evening. According to him, there were times when he had difficulty sleeping at night because of his flank pain, usually about 2-3 times a week. And he wakes up in the morning at 5 oclock. During his hospitalization, the patient verbalized that he had difficulty sleeping due to the hot environmment and discomfort he experiences with his flank pain. He also verbalized that he only takes short naps during his confinement. The group observed that the patient appears sleepy with frequent yawning and dark circleson both eyes. He also verbalized daytime drowsiness.

Norms: A normal sleep hour of an adult per day is 6 - 8 hours without disturbance (Kozier, 2004).

ANALYSIS: The patient has an inadequate number of hours of sleep and rest due to the discomfort he experiences.

13. State of Skin and Appendages The patients general skin color is brown in appearance. His skin is also warm to touch with good skin turgor. He has wound on his right ankle. Hairs on his head are well distributed and are black in color. No dandruff was found. He also has an uncombed hair. His intravenous line is located at his left cephalic vein. His nails are untrimmed and dirty. His nails have no clubbing. His nail beds, palm of the hands and soles of the feet are pink. Nail surface was smooth and its thickness was uniform throughout. His capillary refill returns after two to three seconds.

Norms: Skin varies from light brown to brown. Generally, the skin has uniform color except in areas exposed to the sun, in areas of lighter pigmentation in palms, nail beds, and lips. The hair should

be evenly distributed, thick, shiny and free from infestation (Kozier, 2004). No clubbing of nails should be noted. No distention of abdomen.

ANALYSIS: Warm skin is due to fever.

Anatomy and Physiology The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid

homeostasis in the body, the urinary system controls red blood cell

production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. KIDNEY Our kidneys do a grand job removing the toxic waste products of metabolism. This process is called excretion. Our kidneys produce urine which contains urea, excess salts and excess water.

RENAL CORTEX- The cortex is the outer part of the kidney. This is where blood is filtered.

RENAL MEDULLA- where the amount of salt and water in your urine is controlled. RENAL CAPSULE- Smooth, transparent sheet of irregular connective tissue that is continuous with the outer coat of the ureter.

MINOR CALYX- portion of the urinary collecting system within the kidney that drains one renal papilla.

MAJOR CALYX- portion of the urinary collecting system within the kidney that drains several minor calyces

RENAL COLUMNS- are lines of the kidney matrix which support the cortex of the kidney. They are composed of lines of blood vessels and urinary tubes and a fibrous, cortical material.

RENAL PYRAMID- is conical segments within the internal medulla of the The pyramids contain the secreting apparatus and tubules.

kidney.

RENAL PELVIS- This is the region of the kidney where urine collects. RENAL PAPILLA- tip of renal pyramid projecting into a minor calyx

i. Pathophysiology Book-based

Modifiable -Immunosuppressant -High salt diet -Instrumentation of the urinary tract -Kidney Stones -Urinary retention

Non-Modifiable -Diabetes Mellitus -Pregnancy -Gender: Female

Supersaturation of Urine

Attachment of bacteria to the Urethra

Proliferation of bacteria in the urethra

Introduction of the bacteria into the bladder

Proliferation of bacteria in the bladder

Inflammation of the bladder

Introduction of bacteria to the ureter

Inflammation of the ureter

Infection ascends to the kidney

Activation of the immune response

Inflammation of the renal pelvis

Damage to the kidney

Release of pyrogenes from bacteria

Obstruction of normal urine flow

Loss of non- excretory renal function

Decreased erythropoietin production Release of prostaglandins Urinary stasis Decreased stimulation of the bone marrow

Elevation of the body thermostat by the hypothalamus

Distention of renal pelvis

Urinary output vasoconstriction Increase urine concentration

Flank Tenderness

Decreased erythropoiesis

Shivering

Decreased RBC production

Dysuria Fever Anemia

Client-based

Modifiable -High salt diet -Urinary retention

Non-Modifiable -None

Supersaturation of Urine

Attachment of bacteria to the Urethra

Proliferation of bacteria in the urethra

Introduction of the bacteria into the bladder

Proliferation of bacteria in the bladder

Inflammation of the bladder

Introduction of bacteria to the ureter

Inflammation of the ureter WBC: 13.5 g/L GRAN: 12. 8 g/L

Infection ascends to the kidney

Activation of the immune response

Inflammation of the renal pelvis

Release of pyrogenes from bacteria

Obstruction of normal urine flow

Release of prostaglandins

Urinary stasis

Elevation of the body thermostat by the hypothalamus

Distention of renal pelvis

Urinary output vasoconstriction Increase urine concentration

Flank Tenderness Specific gravity: 1.010

Shivering

Dysuria Fever