Admission date: 01/19/14

Risk factors Pathophysiology: Pyelonephritis

Admitting diagnosis: Pyelonpephritis, or an infection in the kidney, is diagnosed by a CT scan and is most
nephrolethiasis commonly caused by the bacteria E. Coli after a UTI. The inflammatory response from
pyelonephritis, renal calculi,
hematomas in kidneys acute pyelonephritis often causes tissue damage and renal scarring decreasing the function
recurrent UTI
Surgical procedure: stint of the kidney. In this patient, the infectious agent causing the pyelonephritis was of the
and nephrostomy Diabetes Candida species, meaning it was caused by a yeast infection. Thus, proper treatment would
placement include a fungicidal medication.
Pertinent PMH/PSH:
Obesity, HTN, Diabetes,
Obstructive Sleep Apnea,
neuropathy, anxiety, Patient S/S Lab values with discussion of Diagnostic tests with discussion of
arthritis, nephrolethiasis, expected/unexpected findings expected/unexpected findings
kidney stone surgery, Admission s/s:Right flank pain X 4 Hemoglobin = 7 (low due to hematomas CT Scan: shows the development of
recurrent UTI days, vomiting, fever, urinary in kidneys) fluid in the kidneys and dx as
Last V/S, including O2 sat retention Hematocrit=21.5 (low due to hematomas hematoma, also shows right sided
and pain scale: T=99 F in kidneys) staghorn calculi
Current s/s: Sinus tachycardia, Creatinine= 1.56 (elevated due to
P=90 bpm, RR=16, Bloody drainage in nephrostomy, These are expected findings.
decreased kidney function r/t infection)
BP=103/57, O2=97%, right flank pain, fatigue with BUN = 11 (normal, unexpected for patient
Pain=1 dull achy right flank activity, upper respiratory with decreased kidney function)
Current treatments (IV, Glucose = 161 (elevated r/t diabetes)
congestion, productive cough
medications, catheters,
tubes, drains. O2,
ostomies): PICC-single
lumen in right arm,
nephrostomy-right flank, Priority Nursing Diagnoses Priority Assessments
CPAP@night
1. Acute pain AEB patient reporting pain in right flank r/t invasive nephrostomy site
Recommended consults:
nephrostomy procedure, kidney stones, and current infection.
Blood Management - no
2. Activity intolerance AEB patient reporting fatigue, and shortness of lab values: hemoglobin, hematocrit,
blood products Jehovah's
breath during walk and movement r/t lowered hemoglobin and glucose, creatinine, BUN
Witness; Urology, Infectious
hematocrit levels secondary to bleeding.
Ds I/Os and Urinary assessment
3. Ineffective self health management AEB patient verbalizing the
Nutrition: Diabetic Diet
difficulty with prescribed regimens r/t complexity of illnesses. PAIN - location, rating, characteristics of
PT/OT/Speech: None
4. Risk for impaired skin integrity r/t the placement of the pain
Mental Health: A/O x4, HX
nephrostomy, the pressure from the device, and the moisture from
of anxiety
the site.

Clinical Concept Map

 Nursing Diagnosis
Acute pain AEB patient reporting pain in right flank r/t invasive nephrostomy procedure, kidney stones, and current
infection.

Expected Outcomes (2) Interventions with rationale and citation

1. Patient reports pain below stated Outcome #1:
pain goal of 3 on a 0-10 pain scale 1) The nurse will collaborate with the patient to assess pain on a 0-10 pain scale every 2 hours to promote
before discharge. knowledge of the patient's discomfort. (Ackley & Ladwig, 2011)
2) The nurse will collaborate with the patient and patient's wife to discuss the techniques the patient has tried
2. Patient can state 2 methods of and has worked or not worked for the patient to promote knowledge of the individual's preferences.
nonpharmacological pain management 3) The nurse will independently explain to the patient the adverse effects of unrelieved pain to promote the
after nurse educates on pain relief patient's knowledge. (Ackley & Ladwig, 2011)
techniques. 4) The nurse will collaborate with the doctor to obtain a prescription to administer opioid pain medications if
indicated to promote relief from pain and discomfort of the nephrostomy and pyelonephritis. (Ackley, 2011)
5) The nurse will independently explain the pain management plan to the patient to promote the patient's
knowledge. (Ackley & Ladwig, 2011)
6) The nurse will independently assess pain level, sedation level, and respiratory status every 1-2 hours to
promote the knowledge of the nurse and to prevent life-threatening adverse events from the medication.
(Ackley & Ladwig, 2011)
Outcome #2:
Evaluation 1) The nurse will collaborate with the patient to assess pain on a 0-10 pain scale every 2 hours to promote
knowledge of the patient's discomfort. (Ackley & Ladwig, 2011)
1. Goal partially met. Patient reported 2) ) The nurse will collaborate with the patient and patient's wife to discuss the techniques the patient has
pain at 2/10 after lunch; however, the tried and has worked or not worked for the patient to promote knowledge of the individual's preferences.
patient's pain went up just before 3) The nurse will independently explain to the patient the adverse effects of unrelieved pain to promote the
being discharge to a 4/10 on a 0-10 patient's knowledge. (Ackley & Ladwig, 2011)
pain scale. 4) The nurse will independently educate the patient on nonpharmacological pain relief techniques such as
2. Goal met. Patient could explain 2 distraction, imagery, and relaxation. to promote the patient's knowledge. (Ackley & Ladwig, 2011)
methods of nonpharmacological pain 5) The nurse will collaborate with the patient demonstrate the nonpharmacological pain relief techniques and
management. discuss preferences to promote knowledge of the patient. (Ackley & Ladwig, 2011)
6) The nurse will independently explain the pain management plan to the patient to promote the patient's
knowledge. (Ackley & Ladwig, 2011)

Nursing Process Concept Map

 Nursing Diagnosis
Activity intolerance AEB patient reporting fatigue, and shortness of breath during walk and movement r/t lowered
hemoglobin and hematocrit levels secondary to bleeding.

Interventions with rationale and citation

Expected Outcomes (2) Outcome #1:
1. Patient will walk halfway around the 1) The nurse will independently determine the cause of the activity intolerance and whether the cause is
unit without being short of breath by physical, psychological, or motivational to promote knowledge of how to direct interventions. (Ackley & Ladwig,
the end of the shift. 2011)
2) The nurse will independently assess the appropriateness of activity daily to promote knowledge of the nurse.
2. Patient will verbalize the (Ackley & Ladwig, 2011)
understanding of activity and how to 3) The nurse will collaborate with the patient to increase activity levels each day being sure to always be in
gradually increase activity safely before communication with the patient about symptoms and personal goals. (Ackley & Ladwig, 2011)
discharge. 4) The nurse will independently observe for symptoms of intolerance such as pallor, sweating, shortness of
breath, and impaired consciousness when the patient gets up and participates in activity to prevent falls. (Ackley
& Ladwig, 2011)
5) The nurse will independently assess the patient for signs of impaired skin integrity such as ulcers, redness, and
tenderness to prevent the development of ulcers. (Ackley & Ladwig, 2011)
6) The nurse will independently allow time for rest before and after exertion peiods such as meals, showers, and
walks to promote rest for the heart and to conserve energy.

Evaluation Outcome #2:

1) The nurse will independently determine the cause of the activity intolerance and whether the cause is physical,
psychological, or motivational to promote knowledge of how to direct interventions. (Ackley & Ladwig, 2011)
1. Goal MET. Patient walked halfway 2) The nurse will independently encourage families to help the patient to be independent in whatever activities
around the unit without stopping in possible to promote self-care and independence. (Ackley & Ladwig, 2011)
the afternoon. 3) The nurse will independently instruct the client to stop the activity immediately and report to the physician if
the patient experiences symptoms such as increased discomfort, pressure in the chest, back, shoulders, arms,
2. Goal MET. Patient verbalized his
palpitations, weakness and excessive air hunger to promote knowledge of the patient. (Ackley and Ladwig, 2011)
activity habits and plans to improve
4) The nurse will independently instruct the patient on techniques to utilize for avoiding activity intolerance to
his endurance.
promote the knowledge of the patient. (Ackley and Ladwig, 2011)
5) The nurse will independently instruct the patient to use controlled breathing techniques with activity to
promote knowledge of the patient. (Ackley and Ladwig, 2011)
6) The nurse will collaborate with the patient to set up an activity log to record exercise and tolerance levels to
promote endurance and improvement in function. (Ackley and Ladwig, 2011)
 References:

Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed). St. Louis: Mosby Elsevier.

Roberts, James A. (1999) Management of Pyelonephritis and Upper Urinary Tract Infections. Urologic Clinics of North America, 26 (4), 753-763.

Article Summary
The number of hospitalizations due to UTI's is 1,000,000 cases per year with 1/4 of the those including pyelonephritis (Roberts, 1999). The most common infective
agent causing these UTI's is Escherichia Coli (Roberts, 1999). While getting rid of the infection is a priority, the goal of urologists should be to prevent infections which can
lead to scarring and chronic pyelonephrits, or "reflux nephropathy", which can eventually lead to Renal Failure (Roberts, 1999). The scarring of the tissue is caused by the
inflammatory response from the pyelonephritis. Once the tissue is scarred, it loses its function in the kidney which is how it can lead to renal failure.
The symptoms of pyelonephritis may vary depending on age and gender, however many times presents as fever, chills, flank pain and often abdominal pain. In the
elderly, E. Coli is not the most common cause for pyelonephritis. Due to increased catheterization, the infectious agents causing the infection in the elderly include
Pseudamonas, Serratia, and Proteus (Roberts, 1999). Furthermore, pyelonephritis presents differently in the elderly. Their symptoms include GI issues and respiratory
issues (Roberts, 1999).
Sometimes, the pyelonephritis can become a complicated infection with the presence of Diabetes and Kidney Stones. The patient I cared for on Friday had both of
these. The obstruction in this case must be removed and the infection must be treated immediately. The ideal treatment for pyelonephritis is a bactericidal such as a
penicillin or similar antibiotic since the leading cause of the infection is E. Coli which is a bacteria. However, in the patient I took care of had an infection caused by
Candidiasis which would need to be treated with an antifungal medication. Candidiasis, historically uncommon, has shown up more frequently in recent years due to
compromised immune systems of the AIDS virus and the continuous use of antibacterial agents (Roberts, 1999).
In summary, E. Coli is the number one cause of acute pyelonephritis and rapid and thorough treatment to prevent chronic pyelonephritis and kidney failure.
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