Case Study..

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Acute Pyelonephritis Submitted by: Riezel G. Acero Submitted to: Mrs.Vilma Ramoso 1 | Page

Transcript of Case Study..

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Acute Pyelonephritis

Submitted by:

Riezel G. Acero

Submitted to:

Mrs.Vilma Ramoso

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I. Introduction

II. Patient’s Profile

III. Developmental data

IV. Clinical/Admitting Data

V. Health History

a. History of Present Illness

VI. Physical Assessment

a. Nursing Review Chart

b. Nursing Assessment II

VII. Medical Management

a. Drug Study

b. Laboratory Tests and Results

VIII. Nursing Management

a. Actual Nursing Management (NCP)

b. Health Teachings

IX. Recommendations

X. Evaluation

XI. Bibliography

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INTRODUCTIONINTRODUCTION

Acute pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract to the

upper urinary tract. Most episodes of acute pyelonephritis are uncomplicated but hospitalization may be

required .

Pyelonephritis is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney

(nephros in Greek). If the infection is severe, the term "urosepsis" is used interchangeably (sepsis being

a systemic inflammatory response syndrome due to infection). It requires antibiotics as therapy, and

treatment of any underlying causes to prevent recurrence. It is a form of nephritis. It can also be called

pyelitis. Most kidney infections result from lower urinary tract infections, usually bladder infections.

Bacteria can travel from the vagina or anus into the urethra and bladder. Because of the location and size

of their urethra, women are more prone to have bladder infections than men. In both men and women,

lower urinary tract infections may spread to the kidneys, causing pyelonephritis.

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

get pyelonephritis. 

acute uncomplicated pyelonephritis include flank pain, abdominal or pelvic pain, nausea, vomiting, fever

(≥37.8ºC), and/or costovertebral angle tenderness. Fever has been strongly correlated with the diagnosis

of acute pyelonephritis; thus, patients with clinical manifestations of acute pyelonephritis in the absence of

fever should be evaluated for alternative diagnoses . Symptoms of cystitis may or may not be present . In

some cases, the presentation may mimic pelvic inflammatory disease. Rarely, patients with acute

pyelonephritis present with sepsis, multiple organ system dysfunction, shock, and/or acute renal failure

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DEMOGRAPHIC DATADEMOGRAPHIC DATAName: Ms. Emang

Date of Birth: 7.17.88

Age: 23 years old

Sex: Female

Civil Status: Single

Height: 5’2

Weight: 48 kg

Blood Type: Rh + “O”

Religion: Roman Catholic

Nationality: Filipino

Address: Consuelo Purok 4 Magsaysay

Occupation: None

Monthly Income: N/A

Educational Attainment: High School Graduate

Vital sign: Temp: 39.8°C PR: 84bpm RR: 20cpm BP: 90/70mmHg

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DEVELOPMENTAL DATA

Sigmund Freud

According to Sigmund Freud, personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior later in life.

Since my client Emang belongs to the final stage of Sigmund freud according to freud During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person's life. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.

So in the case of my client she is 23 years of age living in the earth. So my client is still single but she have a boyfriend where she could be able to find her happiness to that person. And my client has own individual desire and she really want to have her desire to have her own family. But in her case she is still dependent to her mother because she don’t have a work that’s why she most depend to her parents. But she is still adjusting because she still studying and not yet finish her course that why in relation to freud theory she may have not have establish a balance between the various life areas.

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Formal operational stage

The formal operational period is the fourth and final of the periods of cognitive

development in Piaget's theory.]This stage, which follows the Concrete Operational

stage, commences at around 11 years of age (puberty) and continues into adulthood. In

this stage, individuals move beyond concrete experiences and begin to think abstractly,

reason logically and draw conclusions from the information available, as well as apply

all these processes to hypothetical situations. The abstract quality of the adolescent's

thought at the formal operational level is evident in the adolescent's verbal problem

solving ability. The logical quality of the adolescent's thought is when children are more

likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as

a scientist thinks, devising plans to solve problems and systematically testing

solutions. During this stage the adolescent is able to understand such things as love,

"shades of gray", logical proofs and values. During this stage the young person begins

to entertain possibilities for the future and is fascinated with what they can be. 

In the case of my client is in 23years of age and I know she is able to solve problem to

her own but in some point of time she is still depend to her parents most specially when

money problem arise because she is not able to settle down yet because she is still

studying. But during my interview to her she is able to have plans in life most specially

in the future plan and she really look forward in having a desire to have a better future.

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Erick Erikson

Ego Development Outcome: Intimacy and Solidarity vs. IsolationBasic Strengths: Affiliation and Love

In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful, we can experience intimacy on a deep level.

If we're not successful, isolation and distance from others may occur. And when we don't find it easy to create satisfying relationships, our world can begin to shrink as, in defense, we can feel superior to others.

Our significant relationships are with marital partners and friends.

In the case of my client she belong to initimacy versus isolation.According to Erickson stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful So in the case of my client she has a partner now but its just a temporary partner because their relationship is just boyfriend and girlfriend. So I guess she finds easy towards her partner because they both happy with each other.

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According to havighurts (Ages 12-18) It is Achieving new and more mature relations with age mates of both sexes. Achieving a masculine or feminine social role. Accepting one’s physique and using the body effectively. Achieving emotional independence of parents and other adults. Preparing for marriage and family life. Acquiring a st of values and an ethical system as a guide to behaviour. Desiring and achieving socially responsible behaviour. Achieving a masculine or feminine social role Accepting one’s physique and using the body effectivelyAchieving new and more mature relations with age mates of both sex Achieving emotional independence of parents and other adults preparing for marriage and family life Acquiring a set of values and an ethical system as a guide to behavior Desiring and achieving socially responsible behavior Selecting an occupation.

In the case of my client she is in 23 years of age and she really grow mature now and another thing my client is in the stage of adaptation because she is living in the mountain and now she is now in the city so its quit deferent compare to living in the mountain and in the city place but in the case of her relationship status. She has a quit mature relationship with the guy and also at this point of time she said that she is not ready for married because she still studying and she don’t have enough money for having a family yet. That’s is why as of this time she now preparing for her future through studying.

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In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

The biological changes of ageing, which commence unseen and unfelt during the twenties, make themselves known during the middle years. Especially for the woman, the latter years of middle age are full of profound physiologically-based psychological change. Since most middle-aged people are members of families, with teen-age children ,it is useful to look at the tasks of husband, wife, and children as these people live and grow in relation to one another. Each family member has several functions or roles.

In the case of my client She belong to this stage of havighurts where a period of looking forward during their adolescence and early adulthood. They reminisce about the experience they have before when they still young. A period of looking back. And during my interview she share a some past experience about her life about what had happen about her experience.

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CLINICAL / ADMITTING DATA

Date Admitted: 1-3-12

Time: 9:30am

Physician: Dr. x

Diagnosis: Acute pyelonephritis

Chief Complaint: “ taas kayo akong hilanat og sakit kayo akong tiyan pag mangihi ko”

as verbalized by the patient

HISTORY OF PRESENT ILLNESS

A day prior to admission – client having fever for 38.9 C and appeared weak.

With a complain of abdominal pain with nausea and vomiting.

NURSING SYSTEM REVIEW CHART

NAME: Emang Date: 8-10-11Vital Signs: PR:84 bpm RR: 20 cpm BP:90/70 mmHg Temp:36.5 ºC Height: 5’2 Weight: 48 kg

An [x] is placed in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [x]. EENT:[ ] impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [X] no problemRESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] bronchi[ ] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ x] no problem

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Vomiting

Abdominal pain.

Vomiting

DizzinessHeadache.

Vomiting

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CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] tachycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort [ ] no problemGASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [X] pain[x] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [ ] no problemGENITO – URINARY AND GYNE[ x] pain [ x] urine [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ x] nocturia[ x] assess urine frequency, control, color, odor, comfort[ ] gyne bleeding [ X ] no problemNEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [X] no problemMUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] wound [ ] flushed[ ]atrophy [ ]pain [ ]ecchymosis [ ]diaphoretic [ ]moist[ ] assess mobility, motion gait, alignment, joint function[ ] skin color, texture, integrity [ ] no problem.

NURSING ASSESSMENT

B. Physical Assessment

Assessment Normal Findings Actual Findings

Body Build, Height

and Weight

Proportionate, varies with

lifestyle

Her body is to the height

and weight.

Posture and Gait Clean, neat He appears dirt

Body and Breath

odor

No body or breath odor Have body odor

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Bruise skin color

PNSS 1L @ 30ggts/min infusing well @ the left side.

Patient scale: 6/10

Back pain

Weak

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Signs of Distress No distress noted Signs of distress noted

Signs of Health or

Illness

Healthy appearance She appears weak

Attitude Cooperative She is cooperative

Affect/Mood Appropriate to situation Her mood is appropriate to

the situation

Quantity, Quality

and Organization of

Speech

Understandable, moderate

pace, exhibits thought

association

She understand

moderate and

exhibits thought

association.

Relevance and

Organization of

Thoughts

Logical sequence, makes

sense, has sense of reality

Has a sense to talk

to.

Assessment Normal Findings Actual findings

Uniformity of

skin color

Uniformity except in

areas exposed to the sun

Uniformity

except in areas

exposed to the

sun.

Edema No edema No edema

Skin Lesions No freckles, No

birthmarks, no abrasions

or lesions

No lesions

Skin Moisture Moisture in skin folds

and the axillae

Skin moisture in skin folds and the axillae

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Skin

Temperature

Uniform, within normal

range

She has a fever of

38.9 C

Skin Turgor Skin springs back to

previous state when

pinched

Skin springs back

to previous state

when pinched.

Assessment Normal Findings Yes No

Scalp Evenly distributed

Hair Thickness Thick hair

Hair Texture Silky, resilient hair

Amount of Body Hair Variable

Assessment Normal Findings Yes No

Nail Plate Shape Convex curvature

Texture Smooth

Nail Bed Color Highly vascular, pink,

prompt return of pink color

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Assessment Normal Findings Good Fair Poor

A. Skull and Face

Head Rounded,

symmetrical,

smooth skull

contour, no nodule

B. Eyes and Vision

Eyebrows Hair evenly

distributed,

symmetrical, skin

intact

Eyelid Skin intact, no

discharges, no

discolorations,

symmetrical

Eyelashes Equally distributed,

slightly curved

outward

Conjunctiva Transparent,

sometimes appear

white, shiny,

smooth, pink or red

Lacrimal

Gland

No edema or tearing

Cornea Transparent, shiny

and smooth, blinks

when cornea is

touched

Pupils Black color, equal

size

Near Vision Able to read

newsprint

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C. Ears and Hearing

Auricles Color is uniform,

symmetric, mobile,

firm, pinna recoils

when folded

Response to

Normal

Voice Tone

Normal voice tone

audible

D. Nose and Sinuses

Nares Symmetric and

straight, no

discharges, no

swelling, uniform

color, not tender

Lining of

nose

Nasal septum in

midline

E. Mouth

Lips Buccal

Mucosa

Uniform pink, soft,

symmetrical

Teeth and

Gums

Complete child

teeth, smooth,

white tiny tooth

enamel, pink gums,

moist, firm, no

retractions

Tongue Centrally located,

pink in color, freely

movable

Palates,

Uvula,

Tonsils

Light pink,

smooth, no

discharges,

present gag

reflex.

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Assessment Normal Findings Good Fair Poor

Shape and

Symmetry

Symmetrical

Spinal

Deformities

Spine vertically aligned

Assessment Normal Findings Good Fair Poor

Inspect Neck

Muscles

Symmetrical with head

centered

Observe Head

Movement

Coordinated, smooth,

movement with no discomfort,

equal strength

Assessment Normal Findings Good Fair Poor

Muscle Size is symmetrical, no

contracture, normally firm

Movement Smooth coordinated

movements, equal strength

Bones No deformities, no swelling or

tenderness

Joints No swelling, tenderness

Range of motion Varies to some degree

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LABORATORY RESULT

Date: Jan.3 2012

Examination desired: Complete Blood Count

Specimen: Blood

Rationale:

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

The number of red blood cells (RBCs)

The number of white blood cells (WBCs)

The total amount of hemoglobin in the blood

The fraction of the blood composed of red blood cells (hematocrit)

The mean corpuscular volume (MCV) -- the size of the red blood cells

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

measurements:

MCH (mean corpuscular hemoglobin)

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MCHC (mean corpuscular hemoglobin concentration)

The platelet count is also usually included in the CBC.

Result Normal Range

White cell count 11-500 3.5-10.8 x10^g/L

RBC 2.74 3.9-5.2 x10^g/L

Hgb 10.2 120-160g/dl

Hct 36.8% .37-.45%

Lymphocytes 18% 20-.45%

Neutrophils 50% .48-.73%

Date: Jan.3,2012

Examination desired: U/A

Specimen: Urine

Rationale:

Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of

tests to detect and measure various compounds that pass through the urine.

Color : yellow

Transparency: clear

Sp. Gravity : 1.005

Ph : 7.0

Microscopic Findings

RBC : plenty

WBC : 7-9/hpf

Epithelial cells: moderate

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Bacteria: Few

Crystal: Uric acid crystal few

B. Medical Orders With Rationale

Jan.3,2012

1. Please admit to room of choice under the supervision of Dr. xx

2. Secure consent to care

3. TPR q 4

4. DAT

5. Start IVF with PNSS 1L @ 30ggts/min

Laboratories6. Hematology

7. Urinalysis

To provide care and close monitoring.

Consent is essential for any treatment; routine procedures are covered by a consent signed at admission.

Provide a baseline data for care. During this period of time, complications( hypotension,shock, pulmonary edema) may possibly develop.

Diet as tolerated to maintain nutritional status of patient

To maintain fluid and electrolyte balance

Routine laboratory test upon admission and to assess infection-anemia and or bleeding problem.

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Physical Assessment

MedicationsJan.3,2012

Cefuroxime 750mg IVTT q 8hrs. ( - ) ANST Ranitidine 1 amp. IVTT q 12 Labs to

Metoclopromide 1 amp IVTT now then q 8 prn

PCM 500mg I ab q 6 prn for fever

JANUARY 3 , 2012

Ranitidine amp IVTT q 8 PCM I amp IVTT now ISODREL 5ml now

To screen patient's urine for renal/ urinary detect substances

To assess pt. from head to toe

Gastrointestinal Agent

Antiulcer Agent

Antibiotic Agent

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ANATOMY PHYSIOLOGY

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Urinary System

Pee is one of the first body fluids a kid learns about. You probably learned about pee (also called

urine) when you were 2 or so, when you started using the toilet instead of diapers. Now that you're older,

you can understand much more about the amazing yellow stuff called pee.

Parts of the Urinary Tract

You drink, you pee. But urine is more than just that drink you had a few hours ago. The body produces

pee as a way to get rid of waste and extra water that it doesn't need. Before leaving your body, urine

travels through the urinary tract.

The urinary tract is a pathway that includes the:

Kidneys: two bean-shaped organs that filter waste from the blood and

produce urine

ureters: two thin tubes that take pee from the kidney to the bladder

Bladder: a sac that holds pee until it's time to go to the bathroom

Urethra: the tube that carries urine from the bladder out of the body when

you pee

The kidneys are key players in the urinary tract. They do two important jobs — filter waste from the blood

and produce pee to get rid of it. If they didn't do this, toxins (bad stuff) would quickly build up in your body

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and make you sick. That's why you hear about people getting kidney transplants sometimes. You need at

least one working kidney to be healthy.

You might wonder how your body ends up with waste it needs to get rid of. Body processes such as

digestion and metabolism (when the body turns food into energy) produce wastes, or byproducts. The

body takes what it needs, but the waste has to go somewhere. Thanks to the kidneys and pee, it has a

way to get out.

When you're asked to give a urine sample during a doctor's visit, the results reveal how well your two

kidneys are working. For example, white blood cells in the urine can be a sign of an infection.

Pee also is a way for your body to keep the right amount of water. Did you ever notice that if you drink a

lot, you pee more and the pee is pale yellow? That's because your body is getting rid of extra water and

your pee has more water in it than other stuff.

What's Pee Made Of?

Let's talk more about how the kidneys filter blood. When blood goes through the kidneys, water and some

of the other stuff that is in blood (like protein, glucose, and other nutrients) go back into the bloodstream,

while the excess stuff and waste is taken out. Urine is what is left behind. But what is it exactly?

Urine contains:

water

urea, a waste product that forms when proteins are broken down

urochrome, a pigmented blood product that gives urine its yellowish color

salts

creatinine, a waste product that forms with the normal breakdown of muscle

byproducts of bile from the liver

ammonia

Once pee is produced, it travels from the kidney to the bladder, where it's stored until you need to go to

the bathroom. The bladder expands as it fills; when it's full, nerve endings in the bladder wall send a

message to the brain that you need to pee.

When you're in the bathroom, ready to go, the bladder walls contract and the sphincter (a ringlike muscle

that guards the exit from the bladder to the urethra) relaxes. The urine then flows from the bladder and

out of the body through the urethra. For boys, the urethra ends at the tip of the penis. For girls, it's above

the vaginal opening.

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PATHOPHYSIOLOGY

Pyelonephritis is a common suppuratives inflammation of the kidney and renal pelvis caused by

bacterial infection. Pyelonephritis is usually associated with an infection of lower urinary tract and occurs

more frequently in females. Bacteria infect the kidneys via the bloodstream and from the lower urinary

tract.

Predisposing Factors: Precipitating Factors:

Age = 23y.o. Hygiene

UTI Urination Habit

Gender = female Eating Habit

Prolong Urination

E.coli

(Ascending infection of the urinary tract)Enteric Gran-negative rods, such as E. coli (most important),

Proteus, Klebsiella, Enterobacter, and Pseudomonas are the principal causative agents.

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Ideal: Actual:

Signs and Symptoms Signs and symptoms

Fever > Pain

Nausea and vomiting > Nausea and Vomiting

Dysuria, Frequency > Weakness

Abdominal pain > Fever

Flank pain

Fatigue

Nocturia

Bacteria that reach the pelvis infect the medulla and the collecting ducts, causing tubular epithelial

necrosis, hemorrhage, and stimulate an inflammatory response.

Placement of urinary catheters, increase the likelihood of urinary tract infections.

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

bacterial endocarditis

Vesicoureteral reflux occurs more readily with an uretheral obstruction or cystitis as the urinary bladder

pressure is increased and the normal vesicoureteral valve is compromised.

An ascending infection from the ureter is the most important route and results from the reflux of bacterial-

contaminated urine (vesicoureteral reflux) from the lower urinary tract. 

LABORATORY

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Laboratory result:

Urinalysis:

Color: yellow

Specific Gravity: 1.005

Bacteria: Few

Crystal: Uric acid crystal few

Treatment

Medication Given: antibiotic And IV fluids

Rest, Increase Fluid intake

IDEAL NURSING INTERVENTION

NURSING DIAGNOSIS: Deficient Fluid Volume related to hypermetabolic state

ACTIONS/INTERVENTIONS

Independent

Monitor intake and output (I&O), and correlate with weight changes. Measure blood/fluid losses via emesis, gastric suction/lavage, and stools.

Keep accurate record of subtotals of solutions/blood products during replacement therapy.

Maintain bed rest ; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.

Elevate head of bed during antacid gavage.

RATIONALE

Provides guidelines for fluid replacement.

Potential exists for overtransfusion of fluids, especially when volume expanders are given before blood transfusions.

Activity/vomiting increases intra-abdominal pressure and can predispose to further bleeding.

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Note signs of renewed bleeding after cessation of initial bleeding.

Observe for secondary bleeding, e.g., nose/gums, oozing from puncture sites, appearance of ecchymotic areas following minimal trauma.

Provide clear/bland fluids when intake is resumed. Avoid caffeinated and carbonated beverages.

Collaborative

Administer IV fluids/volume expanders as indicated, e.g., 0.9% sodium chloride, lactated Ringer’s solution;

Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.

Increased abdominal fullness/distension, nausea or renewed vomiting, and bloody diarrhea may indicate rebleeding.

Loss of/inadequate replacement of clotting factors may precipitate development of DIC.

More easily digested and reduce risk of added irritation to inflamed tissues. Caffeine and carbonated beverages stimulate hydrochloric acid (HCl) production, possibly potentiating rebleeding.

Fluid replacement with isotonic crystalloid solutions depends on degree of hypovolemia and duration of bleeding (acute or chronic). Other volume expanders, such as albumin, may be infused until type and cross-matching can be completed and blood transfusions begun. Approximately 80%–90% of gastric bleeding is controlled by fluid resuscitation and medical management without transfusion of blood products.

NURSING DIAGNOSIS: Acute pain related to acute inflammation of renal tissues

ACTIONS/INTERVENTIONS

Pain Management (NIC)

RATIONALE

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Independent

Note reports of pain, including location, duration, intensity (0–10 scale).

Review factors that aggravate or alleviate pain.

Note nonverbal pain cues, e.g., restlessness, reluctance to move, abdominal guarding, tachycardia, diaphoresis. Investigate discrepancies between verbal and nonverbal cues.

Provide small, frequent meals as indicated for individual patient.

Identify and limit foods that create discomfort.

Assist with active/passive range of motion (ROM) exercises.

Provide frequent oral care and comfort measures, e.g., back rub, position change.

Collaborative

Pain is not always present, but if present should be compared with patient’s previous pain symptoms. This comparison may assist in diagnosis of etiology of bleeding and development of complications.

Helpful in establishing diagnosis and treatment needs.

Nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to evaluate extent/severity of the problem.

Food has an acid neutralizing effect and dilutes the gastric contents. Small meals prevent distension and the release of gastrin.

Specific foods that cause distress vary among individuals. Studies indicate pepper is harmful, and coffee (including decaffeinated) can precipitate dyspepsia.

Reduces joint stiffness, minimizing pain/discomfort.

Halitosis from stagnant oral secretions is unappetizing and can aggravate nausea. Gingivitis and dental problems may arise.

Patient may receive nothing by mouth (NPO) initially. When oral intake is allowed, food choices depend on the diagnosis and etiology of the bleeding.

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Provide and implement prescribed dietary modifications.

NURSING DIAGNOSIS: Imbalance nutrition less than body requirements related to ingest food as evidence by nausea and vomiting

ACTIONS/INTERVENTIONS

Independent

Assess/document dietary intake.

Provide frequent, small feedings.

Give patient/SO a list of permitted foods/fluids and encourage involvement in menu choices.

Offer frequent mouth care/rinse with dilute (0.25%) acetic acid solution; provide gum, hard candy, breath mints between meals.

Weigh daily.

Collaborative

RATIONALE

Aids in identifying deficiencies and dietary needs. General physical condition, uremic symptoms (e.g., nausea, anorexia, altered taste), and multiple dietary restrictions affect food intake.

Minimizes anorexia and nausea associated with uremic state/diminished peristalsis.

Provides patient with a measure of control within dietary restrictions. Food from home may enhance appetite.

Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.

The fasting/catabolic patient normally loses 0.2–0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.

Indicators of nutritional needs, restrictions, and necessity for/effectiveness of therapy.

Determines individual calorie and nutrient

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Monitor laboratory studies, e.g., BUN, prealbumin/albumin, transferrin, sodium, and potassium.

Consult with dietitian/nutritional support team.

needs within the restrictions, and identifies most effective route and product, e.g., oral supplements, enteral or parenteral nutrition.

XII. ACTUAL NURSING INTERVENTION

I.

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

O ~ facial grimace

~ guarding at the abdominal area and back

~ vomits 3-4 times a day

A Acute pain related to acute inflammation of renal tissues

P Long term: at the end of 8 hours nursing intervention the pt. will be able to

report pain is relieved.

Short term: at the end of 1-2 hours. the pt. will be able to report pain is

controlled.

I 1. Backrub done

R: To provide nonpharmacological pain management.

2. Encouraged adequate rest periods.

R: To alleviate pain

3. Breathing technique 5 minutes.

R: To alleviate and control pain.

4. Provided quiet environment, calm activities.

R: To promote comfort.

5. administer analgesic

R: To relieved pain.

E At the end of the interventions the goal is partially met because pain is not

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persistently felt. And she is able to controlled pain.

II.

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

O ~ vomiting ~ weak

~ nausea ~ loose bowel movement

A Deficient fluid volume related to hypermetabolic state.

P Long term: at the end of 8hrs. the pt. will be able to back her body fluid to

normal volume.

Short term:at the end of 3hours. the pt. will be able to stable her condition.

I 1. I established fluid replacement needs by encouraging fluid intake.

R: To replace fluid loss.

2. Maintained bed rest; prevent vomiting and straining at stool.

R: Activity/vomiting increases intra-abdominal pressure and can predispose

to further bleeding.

3. Provided oral care.

R: To prevent injury from dryness.

5. Monitored I and O

R: to ensure accurate picture of fluid status

6. Administered IVF PNSS 1L @ 30gtts/min.

R: For fluid and electrolytes replacement.

E At the end of 8 hours nursing intervention the goal was fully met. Because Client

not complain for vomiting.

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III.

S “Wala koy gana mokaon, kay kong mokaon ko ako raman gihapon isuka” as

verbalized by the patient.

O ~ Loss weight

~ inadequate food intake

~ weakness

~ vomiting

A Nutrition Imbalance less than body requirements related to inability to ingest

food as evidence by nausea and vomiting.

P Long term: At the end of this weak the pt’s nutritional status will be stable.

Short term: At the end of 8 hours the patient will be able to regained appetite.

I 1. Promoted pleasant and relaxing environment.

R: To enhance food intake.

2. Promoted adequate/timely fluid intake.

R: (Limiting fluids 1 hour prior to meal decreases possibility of early satiety).

3. Emphasized importance of well-balanced, nutritious intake.

R: To promote wellness.

4. Provided oral care.

R: To promote appetite.

5. Administered IVF PNSS 1L @ 30gtts/min.

R: Serves as parenteral supplement.

E At the end of having nursing intervention the goal is partially met. Bec ause

client regain her appetite partially. She was able to consumed food little but

fairly.

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Drug Study

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