Final Case Study 3rd Edition

SAINT TONIS COLLEGE, INC.
(Formerly: Kalinga Christian Learning Center)

United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@yahoo.com
A Case Study
on
Acute Pyelonephritis
In partial fulfilment
In the subject
NCM 119
ALYONG, JOAN
BANYA-AO, JOYCE
BOCLONGAN, CLARCK
BUMANGOL, CURINA
DELOS SANTOS, JANE
GUIWAN, SHIRRA
LUMASOC, MAILYN JEWEL
PASCUAL, ESTHER
PUYAO, MYRA
SALLAYA, DELISHA GAYE
TANDING, EVA GRACE
Philippines 3800
TABLE OF CONTENTS
I. Introduction ----------------------------------------------- 1
II. Biographic Data ---------------------------------------------- 6
III. Admission Data --------------------------------------------- 6
IV. Nursing Health History --------------------------------------- 7
V. Patterns of Health Functioning ------------------------------ 10-14
VI. Course in the Ward -------------------------------------- 16
VII. Physical Assessment ------------------------------------ 27
VIII. Diagnostic Procedures and Medical Management ---- 32
IX. Anatomy and Physiology -------------------------------- 39
X. Pathophysiology ------------------------------------------- 43
XI. Nursing Care Management -------------------------------- 45
XII. Discharge Plan --------------------------------------------- 48
XIII. References--------------------------------------------------- 51
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I. INTRODUCTION
Acute pyelonephritis is a bacterial infection causing inflammation of the kidneys and is one
of the most common diseases of the kidney. The main cause of acute pyelonephritis is
gram-negative bacteria, the most common being Escherichia coli. In most patients, the
infecting organism will come from their fecal flora. Pyelonephritis occurs as a complication
of an ascending urinary tract infection (UTI) which spreads from 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 two most common
symptoms are usually fever and flank pain. These Symptoms will usually develop within
several hours or over the course of a day. Symptoms of cystitis, such as dysuria and
hematuria, will be present in women usually. In children, common symptoms of acute
pyelonephritis can be absent. Symptoms such as failure to thrive, fever, and feeding
difficulty are most common in neonates and children under 2 years old. Elderly patients
may present with altered mental status, fever, deterioration, and damage to other organ
systems. On physical examination, the patient's general appearance will be variable.
Some patients will appear ill and uncomfortable, while others may appear healthy.
Patients will usually not appear toxic. When a patient is febrile, fever may be high, often
over 103 F. Costovertebral angle tenderness is commonly unilateral over the affected
kidney, but in some cases, bilateral costovertebral angle tenderness may be present.
Suprapubic tenderness during the abdominal examination will vary from mild to moderate
with or without rebound tenderness.Acute pyelonephritis can be divided into
uncomplicated and complicated. Complicated pyelonephritis includes pregnant patients,
patients with uncontrolled diabetes, kidney transplants, urinary anatomical abnormalities,
acute or chronic kidney failure, as well as immunocompromised patients, and those with
hospital-acquired bacterial infections. Uncomplicated, when present in a structurally or
functionally normal urinary tract in a non-immunocompromised host.
Pyelonephritis is more common in women than men, and it often affects individuals who
have a pre-existing urinary tract infection (UTI). Acute pyelonephritis can affect patients of
all ages, however the highest incidence occurs in women aged 15-29. The infection
usually begins in the lower urinary tract and then ascends to the kidneys through the
ureters, which are the tubes that connect the kidneys to the bladder. Risk factors for
developing acute pyelonephritis include urinary tract abnormalities, such as kidney stones
or structural abnormalities, urinary catheterization, pregnancy, diabetes, weakened
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immune system, and sexual intercourse. The typical symptoms of acute pyelonephritis
include high fever, chills, flank pain (pain in the lower back or side), frequent and urgent
urination, pain or burning sensation during urination, cloudy or foul-smelling urine, and
general feelings of malaise. In severe cases, individuals may experience nausea,
vomiting, and even confusion. Prompt diagnosis and treatment of acute pyelonephritis are
crucial to prevent complications and reduce the risk of kidney damage. The diagnosis is
often based on a combination of clinical symptoms, physical examination findings, and
laboratory tests, such as urine analysis and urine culture to identify the causative bacteria.
Imaging studies, such as a kidney ultrasound or a CT scan, may be performed to evaluate
the extent of kidney involvement. Treatment for acute pyelonephritis typically involves
antibiotics to eradicate the bacterial infection. The choice of antibiotics depends on the
severity of the infection, local antibiotic resistance patterns, and individual patient factors.
In some cases, hospitalization may be necessary, especially for individuals who are
severely ill, unable to tolerate oral fluids or medications, or have complicating factors.
According to Matsumoto et al.(2018) suggested that the inflammatory response following
bacterial inoculation is characterized by recruitment of activated neutrophils and
lymphocytes to the renal tissue. This phenomenon was evident in the variation in WBC
count and neutrophils in our study. The WBC and neutrophil counts were significantly
increased in the Acute Pyelonephritis group.
The detected microorganism in the urine culture was Escherichia coli in 12 IUD users.
Use of an IUD is a risk factor for urinary tract infection and should be considered,
especially in women with recurrent urinary tract infections. Urology Journal, Vol. 2 No. 3
(2015)
According to Faye Glenn Abdellah et al (2018) , to maintain good hygiene presence of
disease or bacteria primarily affects the person’s health. One of the reason why people
easily got infected because of poor hygiene. Poor hygiene is the cause of infection that
may worsen if not giving attention. Maintaining our good hygiene is our defense in the
bacteria or in a disease. Providing care in the patient by adding their knowledge on ways
how to maintain a good hygiene .To facilitate maintenance of elimination. In the case of
our patient she does not have a good hygiene pattern. A person must have maintained
his/her hygiene practices in its good condition.
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According to Abdel-Aziz Elzayat et al(2015) reported that genital hygiene habits such as
washing genitals from back to front and having sexual intercourse for more than or equal
to 2 times per week in non pregnant women and women were associated with the
incidence of UTI that if this poor habits continued it will further level up to a disease known
as acute pyelonephritis.
According to Heiskanen T, et al, (2015)numerous studies now provide evidence that host
genetics also influence susceptibility to infection. For recurrent urinary tract infections lead
to acute pyelonephritis have a stronger family histories of Urinary Tract Infection
compared to other women. Both a personal and family history of UTI were strongly
associated with pyelonephritis.
According to Ignacio N. et al, risk factors associated with pyelonephritis in healthy women
are sexual intercourse, use of spermicide, urinary tract infection in the previous 12
months, a mother with a history of urinary tract infection, diabetes, and urinary
incontinence. The most important risk factor for complicated urinary tract infection is
obstruction of the urinary tract. The incidence of drug-resistant microorganisms varies in
different geographical areas. Recent hospital admission, recent use of antibiotics,
immunosuppression, recurrent pyelonephritis, and nephrolithiasis increase the risk of drug
resistance. In accordance to published literature regarding Urinary Tract Infection in
females were in the late-20 and early-30 year age groups.
Neutrophils are the first immune cells to be recruited to the bladder following UTIs, and
they have a predominant role in bacterial clearance. They respond to CXC-chemokine
ligand 1 (CXCL1) and other chemoattractants produced by superficial bladder epithelial
cells, macrophages and mast cells after activation of PRRs by various bacterial products.
In mouse models of UTI, neutrophils can be detected in urine as early as 2 hours post-
infection, and their numbers reach a peak by 6 hours. The number of neutrophils closely
parallels the bacterial burden in the urinary tract, and as bacterial numbers decrease, so
do the number of neutrophilsThe epithelial cells lining the urinary tract are the first line of
defence against pathogens. These cells secrete a plethora of soluble compounds ranging
from pro-inflammatory cytokines to antibacterial agents. Bladder epithelial cells not only
alert the immune system during infection but also directly mediate bacterial clearance by
secreting antimicrobial compounds into the urine and by expelling invading bacteria back
into the bladder lumen to reduce intracellular load.
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For healthy, young, premenopausal women, one of the best ways to avoid acute
pyelonephritis is to focus on the prevention of one of the more common predisposing
causes, which is urinary tract infections. While many factors may lead to urinary tract
infections, a simple way to help in prevention is to void before and immediately after
intercourse, as well as wipe from front to back after urinating and defecating. This will help
to stop the introduction of bacteria into the urethra and subsequent ascending structures.
Aside from behavioral interventions, there have also been studies focusing on cranberry
juice, probiotics, and low dose prophylactic antibiotics to prevent urinary tract infections.
To avoid recurrent acute pyelonephritis, patients must finish the entire course of
antibiotics and take them as directed. Avoiding dehydration also helps to prevent acute
pyelonephritis and improves kidney function.
In the Philippines, pyelonephritis ranks 5th causes of morbidity from 2009 to 2019. The
actual prevalence is unknown, however estimated range from 0.5% 2005 to 2.0% in 2016.
Despite this, the prevalence of bacteraemia and bacteriuria was relatively high (57.4%
and 73.5%, respectively). Escherichia coli accounted for the majority of causative
organisms. The mortality rate for patients with pyelonephritis has been reported to be
1.2% to 33% 2014.
The total projected population of kalinga is 122,826 and total mortality rate by Provincial
Health Office as of year 2022 on acute pyelonephritis was 0.70% with a total death of 2
both female (PHO-KALINGA).
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RATIONALE FOR CHOOSING THE CASE

We choose to study this case for us to have a knowledge about acute pyelonephritis that helps in
managing and caring for patients who are affected by the condition and to promote awareness to
our understanding regarding to the complications that can arise, such as sepsis or kidney abscess,
and implementing appropriate interventions to prevent and manage these complications.
Understanding this study will equips healthcare providers with the necessary tools to ensure
optimal patient care and outcomes and can improve patient outcomes, prevent complications, and
work towards reducing its burden on individuals and society.
Learning Objectives
This case presentation seeks to provide different information about the disease to be presented and
about the client being considered with the following specific objectives.
1.Give a brief introduction about Acute Pyelonephritis together with its signs and symptoms.
2.Discuss the theoretical framework that is related to the client’s condition.
3.Present the client’s demographic data and health history with its Gordon’s pattern of functioning.
4.Present the abnormal results of the Physical Assessment made on the client.
5.Present the different laboratory results or test done to the client with its interpretation. 6.Discuss
the normal Anatomy and Physiology of the Urinary system.
7.Explain the Pathophysiology of Acute Pyelonephritis.
8.Discuss the drugs prescribed to the client by a Drug Study.
9.Present an appropriate Nursing Care Plan for the most prioritized problem.
10.Give a Discharge Plan that the client may use upon discharge to the hospital.
11.Present our references as well.
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II. Biographic Data

Name of Client: PATIENT M
Age: 22 YEARS OLD
Sex: FEMALE
Address: MASABLANG, TABUK CITY, KALINGA
Nationality: FILIPINO
Birth date: JANUARY 28, 2001
Birth place: MASABLANG TABUK CITY
Religion: UCCP
Educational Attainment: STUDENT 2ND YEAR COLLEGE
Occupation: STUDENT
Civil Status: MARRIED
Height: 4’11
Weight: 65.5
III. Admission Data

Chief Complaint: HEADACHE, FEVER, BODY PAIN
Date of Admission: APRIL 24,2023
Provisional Diagnosis: ACUTE PYLONEPHRITIS
Attending Physician: CLIFFORD JOHN R. GACUYA, M.D
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IV. Nursing Health History

A. HISTORY OF PRESENT ILLNESS
Before hospitalization, the patient stated that she urinates approximately 4 times a day and
describes it as little and dark in color. She had a normal defecation pattern approximately once a
day. She wasn’t a peaky eater and drinks more soft drinks especially Coca-cola rather than water.
The patient had an active lifestyle as she preferred to do household works rather than doing
nothing. She described her sexual-reproductive pattern as active. But seldom practiced personal
hygiene after having sexual activity. And she wiped her vagina to anus from back to front and
sometimes she forgot to douch everytime she urinates. She also had no known allergies to food or
drugs.
Prior to admission, the patient had been having numbness and muscle cramps on her arms, legs,
and back area for 3 days. She took a pain reliever tablet with the brand name Biogesic 500mg to
ease the pain, but after 4 hours, the pain reoccurred with headaches, joint pain, and fever. On April
24, 2023, the patient decided to go to the hospital with a chief complaint of joint and body pain
with pain scale of level 8, headache, fever, vomit once, and burning in urination. She described the
pain on back area as sharp and constant but doesn’t radiate. Upon assessment, the patient appeared
irritable, weak and with the vital signs as follows: BP of 100/60 mmHg, pulse rate of 74 bpm,
respiratory rate of 20 bpm, temperature of 38.4 degrees Celsius, weight of 65.5 kg, and height of
150 cm.
The patient was admitted at 6:45 a.m. on April 20, 2023, to Kalinga Provincial Hospital by the
resident on duty, Dr. Clifford John Gacuya. The attending physician diagnosed her with the
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admitting diagnosis of Systemic Viral Infection and arrived at principal diagnosis of Acute
Pyelonephritis.
B. Past Medical History (Other)
The patient was ten years old when she had her menarche. She received complete doses of her
vaccinations ever since she was a kid. She had no history of abortions or miscarriages. Aside from
seasonal fever and cough, she had no history of serious childhood disease except for URINARY
TRACT IINFECTION (UTI).
She had a long history of recurring urinary tract infections that began when she was 12 years old.
She experienced fever and strong urged to urinate with no urine. On July 30, 2015, she was
confined at Saint Peter Claver Hospital for 3 days. His physician, Dr. Ariel D. Cayadan diagnosed
her with Urinary Tract Infection(UTI) and prescribed cefotaxime. In 2018, she also experienced
the same symptoms of fever, painful urination then decided to go to the hospital for check-up but
her physician admitted her for 3 days due to Urinary Tract Infection. She again developed Urinary
Tract Infection on her first pregnancy during her second trimester March 2020, but it disappeared
when she took prescribed oral antibiotic cephalexin by her OB-GYNE physician Dr. Marriane
Rowena Baggay. She was 19 years old when she delivered her first baby in 2020 via Cesarean
Section. On January 12, 2022, she delivered her second baby via Cesarean section. After that, she
tried birth control methods and had her Contraceptive Implant (Nexplanon) placed on her left
arm as suggested by her physician. After a year of using a contraceptive implant, she decided to
remove it because she felt it didn’t suit her. From that time on, she stopped having her menstrual
periods. Then she immediately switched to contraceptive pills and took them for a month, during
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which she had her normal menstruation. On March 7, 2023, after one month of using pills, she
went to Rural Health Unit 1 to have a contraceptive injection (Depo-Provera) because she always
forgot to take her pills, but health care professionals advised her to have an Intrauterine Device
(IUD) that she still used it until now.
C. FAMILY MEDICAL HISTORY AND GENOGRAM

Grandmother Grandfather
Kidney Failure
Father Mother
Mother Father
Patient Husband
Son Son
9
Legend:
Male Female

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V. PATTERNS OF HEALTH FUNCTIONING (GORDON’S FUNCTIONAL
10
Pattern of Before During Analysis
Health Hospitalization Hospitalizatio
Functioning n
Health Patient defined Patient stated Health is a way of thinking,
Perception SAINT TONIS COLLEGE,revolves
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that I am able toKalingaI’m
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Christian not Center)
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Purok 4, Bulanao Centro, Tabuk City, Kalinga (Fundamentals of Nursing
Pattern family in doing Philippines
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rest for my own
good.
Nutrition- The patient Patient stated An individual’s health
Metabolic stated that she that her status greatly affects
Pattern has a good appetite is the eating habits and
appetite and nutritional status
same and she
she eat meals (Fundamentals of
drinks 1.5 Nursing by Kozier
three times liters of water
per day with p.1178). Patient’s
throughout nutritional status has
one snack in
the day. She is been changed due to
the afternoon
also placed in her confinement and
between 3pm. diet.
Her favorite low salt, low
snack is French fat diet.
fries and
bread. She
usually eats
fried chicken,
meat pork. She
has no allergy
in food. She
only drink 2
glasses of
water a day
and she drinks
more
softdrinks and
consumed 1
liter 3x a week.
She drinks 1
glass of coffee
between 5-
11
6pm.
Elimination The patient During her Elimination is
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VI. Course in the Ward (Doc Orders)
Date and Time Doctors Order Rationale Nursing Responsibilities
April 24, 2023 Admit patient to FM For further monitoring.  Admitted the
ward management, and patient as ordered
6:45 am
evaluation of patient's  Prepared and filled
condition. out necessary
documents
 Obtained initial vital
signs and recorded
 Assisted the patient
to room of choice
Secure Consent For legal purposes and to  Served as a witness

ensure that the patient  Validated
understands the nature of understanding of
the treatment the patient & SO
about the
importance of
signing consent.
TPN every shift TPN is a nutritional solution  Maintain aseptic

that is infused into the body technique in
through a vein or is catheter
consumed by mouth. TPN is maintenance and
given intravenously in order TPN administration
to bypass the digestive tract  Glucose should be
and feed directly into the
monitored several
bloodstream. The goal of
times a day until
TPN is to prevent or treat
stable, and then at
malnutrition related to
various health conditions by least daily.
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ensuring that all daily  Monitored intake

nutritional requirements are and output as well
met. as weight daily.
DAT To maintain patient’s  Informed and

nutritional status. explained to the
patient and
significant others
about the ordered
diet.
 Enumerate foods
that are allowed and
not allowed for the
condition of the
patient.
 Informed the
dietary department
regarding the diet of
the patient.
Diagnostics:  Verified doctor's

order
CBC -To evaluate alterations in
blood components  Informed the
patient about the
-To help identify primary diagnostic exams
ECG
conduction abnormalities,  Monitored patient
cardiac arrhythmias, cardiac during diagnostics
hypertrophy, pericarditis,
procedures.
electrolyte imbalances,
 Filled out necessary
myocardial ischemia, and
request forms
the site and extent of
myocardial infarction. As  Informed the
well as to monitor recovery laboratory
from an MI. department about
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-To measure the nitrogen the exams

fraction of urea and would  Followed up results
BUN
aid in the diagnosis of Acute and attached it to
glumerulonephritis. the patient's chart.
-To assess creatinine levels
that would diagnose
Crea presence of Acute
glomerulopehritis
-To assess presence of uric

acid level in the blood
BUA
-To determine alterations in
urine components
UA
IVF: PNSS 1L x 16 For hydration and to  Verified doctor's

hours facilitate fluid and order
electrolyte replacement and  Regulated IVF
serve as an access for IV correctly and
medications. labeled it.
TF: PLRS 1L x 16 Plain Lactated Ringer's  Verified doctor's

hours solution. Maintenance of order
fluids and electrolytes  Regulated IVF
correctly and
labeled it.
Medications:  Verified doctor's

order
Ceftriaxone qn IV - Use to treat a wide variety
every 12 hours of bacterial infection  Performed skin
ANST testing
 Clean the IV port
prior to
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Paracetamol 300mg -To decrease fever administration of

IV for T-38°c drugs
 Monitored patient
Paracetamol 500mg
-To relief fever, headache for adverse effects
1 tab per orem
and pain  Assessed patient's
every 4 hours
fever or pain.
 Instructed patient to
take prescribed
medications with
the right time, right
route and right
dosage.
V/S every 2 hours/ To obtain baseline data of  Monitored V/S

record vital signs and monitor every 2 hours,
condition of patient until recorded and
stable. reported
immediately any
deviations.
Refer For further assessment and  Referred and

treatment. endorsed
accordingly.
April 25, 2023 Continue IVF and For the patient to complete  Verified doctor's
meds the medication regimen and order
5:55 am
for continuity of care.  Regulated IVF
correctly and
labeled it.
 Ensuring that the
right medication is
properly drawn up
in the correct dose,
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and administered at
the right time
through the right
route to the right
patient.
VII. Physical Assessment
A. Review of System
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SYSTEM NORMAL ACTUAL INTERPRETATIO

FINDINGS FINDINGS N & ANALYSIS
1.Integumentary The skin is typically Upon inspection and Due to local tissue
System intact, without any palpation the skin is infection or
signs of infection or typically intact, with inflammation can
inflammation signs of infection or make the localized
inflammation as area feel warmer
associated with skin than the surrounding
redness and warmth skin.
and the skin is moist.
2.Respiratory Normal chest shape, Normal chest shape, NORMAL
System with no visible with no visible
deformities, such as a deformities, such as a
barrel chest, barrel chest,
kyphosis, or scoliosis. kyphosis, or scoliosis.
No muscle retractions No muscle retractions
when breathing. when breathing.
Quiet, unlabored Quiet, unlabored
respirations with no respirations with no
use of accessory, use of accessory,
neck, shoulder, or neck, shoulder, or
abdominal muscles. abdominal muscles.
3.Cardiovascular In a normal In a normal NORMAL
system cardiovascular cardiovascular
system, heart rate and system, heart rate and
blood pressure blood pressure
remain within the remain within the
normal range for the normal range for the
individual.
individual.
4.Nervous system The patient is alert The patient is alert NORMAL
and oriented to and oriented to
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person, place, and person, place, and

time with normal time with normal
speech. No motor speech. No motor
deficits are noted, deficits are noted,
with muscle strength with muscle strength
5/5 5/5
bilaterally. Sensation
bilaterally. Sensation
is intact bilaterally.
is intact bilaterally
5.Musculoskeletal Erect posture with Upon inspection and Severe loss of kidney
System good balance and palpation the patient function causes
normal gait while muscles and joints metabolic wastes to
walking. Joints and are tender to touch build up to higher
muscles are and warmth and there
symmetrical with no levels in the
is presence of redness blood. Damage to
swelling, redness, or
with muscle twitches muscles and nerves
deformity. Active
and low back pain
range of motion of all can cause muscle
joints without with a rating scale of
twitches, muscle
difficulty. No spine 8/10.
weakness, cramps,
curvature.
and pain.
6. Gastrointestinal Abdomen is soft, Upon inspection the When we are sick
System non-distended, “Client grimacing with an illness that
non-tender with with shallow irregular leads to vomiting, the
positive bowel breathing. Abdomen lining of the
sounds to all four distended.” gastrointestinal (GI)
quadrants. tract is typically
inflamed and
irritated. When you
try to eat or drink,
you further irritate
that lining, causing it
to expel the contents
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of your stomach.
Vomiting is the
body's way of getting
rid of harmful
substances from the
stomach, or it may be
a reaction to
something that has
irritated the gut.
7. Genitourinary Clear, pale yellow Dark or bloody urine, Due to increase
System urine foul odor, or number of red blood
sediment present cell in urinalysis lab,
Absence of pain, test,
urgency, frequency, Dysuria
or retention RBC:7/HPF
Urinary frequency
NORMAL
Urinary urgency VALUES:0-5 RBCs
Per high- power field
Urinary retention
(HPF)
8.Reproductive No obstruction and The patient has no Common IUD side

System abnormalities, normal abnormalities in her effects include:
size and shape in reproductive organs. irregular bleeding,
ovaries, fallopian She is having a lighter or shorter
tubes, uterus, cervix shorter periods or periods.
and vagina. Regular light menstrual flow
normal duration of due to her intra
menstrual bleeding uterine device.
and no excessive
pain. No difficulties
in sexual
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performance,
adequate vaginal
lubrication.
9.Immune system The immune system The immune system Due to increase
produces antibodies triggers an number of
to target the specific inflammatory neutrophils
bacteria causing the response to eliminate
0.72
infection. These the invading bacteria.
antibodies help in Immune cells such as NORMAL VALUES:
neutralizing the neutrophils are
bacteria and aiding in recruited to site of O.55-0.65
their elimination. infection.
Antibodies can be
detected in blood
tests, such as a urine
culture or serological
tests.
1O. Endocrine Thyroid gland is Thyroid gland is Due to hormonal
System symmetrical and non normal, hair growth, imbalances and the use
tender, stable weight, skin, blood pressure of spermicide like Intra
normal distribution of and face, but the Uterine Device (IUD).
hair , skin appears menstrual cycle have
normal without irregular bleeding or
dryness, discoloration periods with a
or thinning, blood minimal flow of
pressure within the blood.
normal range, regular
menstruation periods
with normal flow and
duration and the
patient does not
exhibit any physical
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characteristics
associated with
excess corticol, such
as a moon face or
buffalo hump.
11.Hematologic The red blood cell Elevated neutrophils Neutrophilia is often
System normal count 8.500 per microliter. seen in response to
approximately 4.5- bacterial infections
5.5 millions cell per such as urinary tract
microliter(mcL) for infections. Elevated
males, and 4.0-5.0 neutrophils help the
millions cell per body to combat and
microliter(mcL) for
eliminate
females. Normal size
microorganisms.
and shape. White
blood cells are in a Elevated neutrophils
normal range is indicated there is
including bacterial infections,
neutrophils:1,450 to emotional,
7,500 neutrophils medication drugs
per microliter.,
such as
lymphocytes:20-40%,
corticosteroids.
Monocytes: 2-8%,
eosinophils:1-4%,
basophils:0.5-1%.
hite blood cell,
platelets and plasma
are in a normal range.
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12.Psychiatric Stable mood, healthy Stable mood, healthy NORMAL

System coping mechanism coping mechanism
engaging to activities engaging to activities
that promote well that promote well
being, adequate being, adequate
social relationships social relationships
including friendships, including friendships,
family family
connections,and connections,and
romantic romantic
partnerships. Balance partnerships. Balance
sleep patterns, sleep patterns,
postive self image, postive self image,
health self esteem health self esteem
positive perception of positive perception of
themselves and their themselves and their
abilities.. abilities..
B. Physical Assessment (Please refer to Kozier’s Physical Assessment Format)

Area Assessed Normal Findings Actual Findings Interpretation
a. SKIN Varies from light to Upon palpation the Due to changes in

deep brown, from skin is moist, flushing blood circulation due
ruddy pink to light (redness) and warm to to increase body
pink, from yellow touch. temperature.
overtones to olive,
generally uniform
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skin temperature.
b. HAIR Thick, silky, Thin silky, resilient, Normal

resilient, free from evenly distributed and
infestation evenly is able to cover the
distributed and whole scalp. There is
covers the whole no infestation noticed
scalp
c. NAILS Convex curvature Upon inspection the By adopting proper

smooth texture, patient nails visible hand nail care
highly vascular and dirt, grime, or debris practices, individuals
pink, prompt return trapped underneath can maintain clean,
of pink less than 3 them. Long nails and well groomed nails,
seconds. uneven nail edges that reduce the risk of
are not trimmed. infections and
promote good hand
hygiene habits.
d. NECK Symmetrical and Symmetrical and Normal

REGION straight, no palpable straight, with palpable
lumps, and supple lumps.
trachea is on midline
of neck, and spaces
are equal on both
sides.
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e. LUNGS Symmetrical chest Symmetrical chest Normal

expansion, clear expansion, clear
breath sounds. breath sound
f. HEART Normal rate, regular No palpitation, Normal

rhythm no murmur murmur
g. PERIPHERAL Symmetrical pulse Symmetrical pulse Normal

volume full volume, full pulsation
pulsation.
h. BREAST Round shaped, Symmetrical, slightly Normal

slightly unequal in unequal in size,
size, generally without tenderness or
symmetrical, no masses, no discharge.
tenderness, masses,
nodules or nipple
discharge
i. ABDOMEN Uniform color Upon palpation No Due to fluid

rounded symmetrical scars seen upon accumulation gas
contour, audible inspection. Uniform in build up or digestive
bowel sounds, color, but abdomen is contents.
tenderness liver and distended.
bladder are not
palpable
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j. UPPER and Equal size on both Equal size on both NORMAL

LOWER sides of the body sides of the body
EXTREMITI upper and lower upper and lower
ES extremities extremities
SKULL Proportional to the Proportional to the

size of the body, size of the body,
NORMAL
round with round with
prominences in prominences in frontal
frontal and occipital and occipital area,
area, symmetrical in symmetrical in places.
places.
FACE Oblong or round or Round shaped, Normal

square or heart symmetrical with no
shaped, symmetrical, involuntary muscle
facial expression that movements. She has
is dependent on the facial grimace and
mood or true feeling or discomfort
feelings and no
involuntary muscle
movements
NOSE Midline symmetrical Midline symmetrical Normal

and patent, no and patent, no
discharge discharge.
MOUTH Symmetrical, gums, Symmetrical, gums Normal
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pinkish in color, lips pinkish in color, lips

margin is margin is
symmetrical no symmetrical, no lesion
lesion and and tenderness, with a
tenderness, without jacket on the 2 upper
involuntary incisors
movement
EYES Parallel and evenly Parallel and evenly Normal
spaced symmetrical, spaced pupils are
non- protruding, bluish gray in color,
pink palpebral equal in size.
conjunctiva and
pupils black in color,
equal in size, round
and constricts in
response to light
EARS Parallel symmetrical, Parallel symmetrical Normal
proportional to the proportional to the
size of the head, size of the head, bean-
bean-shaped, skin is shaped, skin is same
same color as the color as the
surrounding color, surrounding color,
clean firm cartilage clean and firm
cartilage.
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VIII. Diagnostic Procedure & Medical Management
A. Diagnostic Procedure
Date Diagnostic Actual Findings Normal Interpretation &
procedure Findings Analysis
April 23,2023 Blood Urea 3.94 3.0 – 8.82 The result of the
Nitrogen mmol/L patients Blood
Urea Nitrogen is
in the normal
range.
Serum Creatinine 68.80 44 – 105 The result of the

µmol/L patient’s Serum
Creatinine is in
the normal
range.
Blood Uric Acid 232.51 155 – 357 The result of the

µmol/L patient’s Blood
Uric Acid is in
the normal
range.
Hemoglobin 1.52 120 – 160 g/l The actual

findings of the
patient’s
Hemoglobin is in
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the normal
range.
Hematocrit 0.42 0.37– 0.43 The result of the

patient’s
Hematocrit is in
the normal
range.
RBC Count 4.70 4.0- The result of the

5.4X10*12/L patient’s RBC
Count is in the
normal range.
MCV 89 80 – 100 fl The result of the

patients Mean
Corpuscular
volume is in the
normal range.
MCH 32 27 – 31 pg The result of the

patients Mean
Corpuscular
Hemoglobin is in
the normal
range.
MCHC 364 310 – 360 g/l The result of the
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patients Mean
Corpuscular
Hemoglobin
Concentration is
in the normal
range.
WBC Count 4.1 4.0 – 10 The result of the

0x10^9/L patient’s WBC is
in the normal
range.
Neutrophil 0.72 0.55-0.65 The result of the

patient’s
Neutrophil is
above normal
this is a sign that
your body has
an infection.
Lymphocytes 0.24 0.25-0.35 The result of the

Lymphocytes
patient’s is in
the normal
range
Monocytes 0.04 0.03-0.06 The result of the

Monocytes
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patient’s is in
the normal
range
Platelet Count 229 NB: 84- The result of the

478x10^9/L Platelet Count
150- patient’s is in
400x10^^9/L the normal
range
Transparency Hazy Clear The result of the

patient’s urine
transparency is
above normal
which is a sign of
urinary tract
infection caused
by blood cells or
mucus in the
urine.
Color Yellow Yellow The result of the

(light/pale to patient’s urine
dark/deep color is in the
amber normal range
Epithelial Cells Moderate Few The result of the

patient’s
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epithelial cells is
above normal
which indicate a
yeast or urinary
tract infection
Pus Cell 12-15 0-5/hpf The result of the

patient’s pus cell
is above normal
which indicate a
urinary tract
infection
Red Blood Cell 7 4 RBCs/HPF The result of the

patient’s red
blood cells is
above normal
known as
hematuria which
indicate an
urinary tract
infection or
kidney disease
Mucus Threads Many Small or The result of the

moderate patient’s mucus
threads is above
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normal maybe a
sign of urinary
tract infection
B. MEDICAL MANAGEMENT
Drug name Classification Indication Mechanism of Side effect Nursing

action consideration
Ceftriaxone Antibiotic Indicate Works by inhibiting - Head ache -Do skin
cephalosporin patients with the mucopeptide - Dizziness testing
neurologic synthesis in the - Pain
complication, bacterial cell wall. - Induration -Asses
carditis and The beta-lactam - Phlebitis patients
arthritis. It moiety of - Rash previous
also effective ceftriaxone binds to - diarrhea sensitivity
in Gram carboxypeptidases, - Thrombocytosis reaction to
negative and transpeptidases, penicillin or
- Respiratory
infections, endopeptidases in other
superinfection
meningitis, the bacterial cephalosporin
gonorrhoea cytoplasmic
It is also for membrane. These -Assess
bone and joint enzyme that involve patient sign
infection, cell wall synthesis and symptoms
lower and cell division. of infection
respiratory By binding to these before and
tract enzymes, during the
infection, Ceftriaxone results treatment
middle ear in the formation of
infection and defective cell walls -Monitor
urinary tract and cell death. hematologic,
infection electrolytes,
renal and
hepatic
reaction
-Monitor sign
of allergic
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reaction
Paracetamo Analgesic Temporary Thought to produce - Rash -Assess

l reduction of analgesics by - Swelling patient fever
fever, blocking pain - Nausea or pain
temporary impulses by - Vomiting
relief of inhibiting synthesis - Constipation -Assess
minor aches of prostaglandin in allergic
and pain the CNS or of other reaction
caused by substances that
common cold sensitize pain -Assess and
and influenza, receptor to monitor vital
head ache, stimulation. sign
sore throat,
toothache, -Report any
backache, and unusual
menstrual swelling,
cramps. severe
dizziness
And trouble
breathing
Cefixime Antibiotic Cephalospori Like all beta-lactam - Diarrhea -Asses overall

n drug which antibiotics, - Stomach pain condition of
acts as an cefixime binds to - Rash patient
antibiotic and specific penicillin- - Itching especially for
helps to fight binding proteins - Trouble sign of
different (PBPs) located breathing infection
bacterial inside the bacterial - Nausea
infections cell wall, causing - vomiting -Assess for
such as the inhibition of the allergic
gonorrhoea, third and last stage reaction and
bronchitis, of bacterial cell anaphylaxis
and bacterial wall synthesis
infections of -Assess renal
throat, ears, function
and urinary before and
tract by during therapy
hampering the
growth of
various
bacteria.
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IX. Anatomy & Physiology

The urinary system's function is to filter blood and create urine as a waste by-product. The organs
of the urinary system include the kidneys, renal pelvis, ureters, bladder and urethra.
The kidney and urinary systems help the body to eliminate liquid waste called urea, and to keep
chemicals, such as potassium and sodium, and water in balance. Urea is produced when foods
containing protein, such as meat, poultry, and certain vegetables, are broken down in the body.
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Urea is carried in the bloodstream to the kidneys, where it is removed along with water and other
wastes in the form of urine.
Other important functions of the kidneys include blood pressure regulation and the production of
erythropoietin, which controls red blood cell production in the bone marrow. Kidneys also regulate
the acid-base balance and conserve fluids.
Kidney and urinary system parts and their functions
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 Two kidneys. This pair of purplish-brown organs is located below the ribs toward the
middle of the back. Their function is to:
o Remove waste products and drugs from the body
o Balance the body's fluids
o Release hormones to regulate blood pressure
o Control production of red blood cells
The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron
consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a
renal tubule. Urea, together with water and other waste substances, forms the urine as it passes
through the nephrons and down the renal tubules of the kidney.
 Two ureters. These narrow tubes carry urine from the kidneys to the bladder. Muscles in
the ureter walls continually tighten and relax forcing urine downward, away from the
kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop.
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About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the
ureters.
 Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in
place by ligaments that are attached to other organs and the pelvic bones. The bladder's
walls relax and expand to store urine, and contract and flatten to empty urine through the
urethra. The typical healthy adult bladder can store up to two cups of urine for two to five
hours.
 Two sphincter
muscles. These circular
muscles help keep
urine from leaking by
closing tightly like a
rubber band around the
opening of the bladder.
 Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the
bladder.
 Urethra. This tube allows urine to pass outside the body. The brain signals the bladder
muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain
signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When
all the signals occur in the correct order, normal urination occurs.
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https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-urinary-
system#:~:text=The%20urinary%20system's%20function%20is,and%20converts%20them
%20to%20energy.
X. Pathophysiology
Precipitating Factors:
Predisposing Factor: Family History
Unhygienic Practice Gender- Female

Sexually Active
Age- 15-29y/o
Spermicide Use
I.
Etiologic agent
Escherichia coli
Proliferation Multiplication of anaerobic

of microorganism from the bacterium gram negative
anus to theurethral orifice bacteria in the urethra
Burning while urinating
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Spread to the bladder
Traveling to the ureters
Infection
Infection Reaches
Reaches renal
renal pelvis
pelvis
and
and kidneys
kidneys
Ascending Infection of Urinary

Tract
Pyrexia Flank Pain Hematuria Vomiting

(Fever) (Body Malaise)
Acute Pyelonephritis
39
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Nursing Care Management

XI. Nursing Care Plan
1.Hyperthermia
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Data: -Hyperthermia -After 1 hour of -Identify underlying -After 1 hour of
“Nagpudut riknak related to nursing cause. nursing intervention
ingana ulu ken saka” inflammation intervention the -Note chronological and the patient
as verbalized by the and infectious patient will be able developmental age of verbalized
patient. process, as to maintain a core client. temperature is
evidenced by temperature that is within normal range.
an increase in within normal -Monitored core
Objective Data: body range. temperature, note the
temperature of presence of temperature
-Weakness elevation.
38.4 degrees
-Flushed skin Celsius. -Assessed whether the
-Irritability temperature reflects
heatstroke.
-Vital signs taken as
follows; -Provided Tepid sponge
bath.
BP- 100/60mmHg.
-Encouraged to increase
PR-74bpm
oral fluid intake.
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RR-20cpm -Assessed neurological

Temp-38.4 degrees response, noting the
Celsius. level of consciousness
and orientation, reaction
to stimuli, reaction of
pupils and presence of
posturing or seizure.
-Monitored Respiration.
-Auscultated breath
sounds, noting
adventurous sounds
such as crackles.
-Monitored and record
all source of fluid loss
such as urine.
-Note the presence or
absence of sweating as
the body attempts to
increase heat loss by
evaporation.
2. Body Malaise
ASSESSMENT DIAG PLANNING INTERVENTION EVALUATION

NOSIS
Subjective data: -Body -Short Term -Assess patient ability to Short Term Goal:
“Kailangak pay ti ag malais Goal: perform task/ noting After 2 hours of nursing
alalay kenyak nu e After 2 reports of weakness, intervention, the patient was able
apan nak umisbu” as related hours of Fatigue and difficulty to cope with Fatigue as evidenced
verbalized by the to nursing accomplishing task. by verbalization of feeling of
patient Fatigu intervention, -Recommended quit comfort and participating in
e as the patient environment/atmosphere. passive ROM.
eviden will be able
Objective data: ced by -Encouraged bed rest.
to cope with
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-Appeared weak. weakn Fatigue as -Provided assistance in

-Unable to perform ess. verbalize by doing ADLs or desired
activities of daily feeling of activity.
living. comfort and -Review familial or
increase physiological factors.
-Dependent on others activity
care. participation. -Note cultural factors
-Vital signs taken as that may influence
follow; anxiety.
BP-100/60mmHg -Established a
therapeutic relationship,
PR-74bpm conveying empathy and
RR-20cpm unconditional positive
regard.
Temp-38.4 degrees
Celsius. -Observed behavior
3. Deficient Knowledge
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Deficient -After 8 hours -Ascertain level of -After 8 hours
data: knowledge of nursing knowledge, including of nursing
“Haan nak ag related to intervention anticipatory needs. intervention,
bugbuggu nu insufficient the patient -Determined the The patient
umisbu nak” as interest in will verbalize client’s ability, verbalized
verbalized by learning. understanding readiness and barriers understanding
the patient. of condition, to learning. of the
disease condition,
process and -Identify support disease process
Objective Data: treatment. individuals/significant and treatment.
other requiring
-Inaccurate information
follow through
of instructions -Assessed the level of
or performance the client's
on a test or capabilities and the
procedure. possibilities of the
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-Refuse to ask situation.

question. -Identify motivational
-Vital signs factors.
taken as follow: -Provided information
BP- relevant only to the
100/60mmHg situation
PR-74bpm -Educated on proper
RR-20cpm hygiene.
Temp-37.4 -Observed for

degrees possible barriers that
Celsius. might make learning
more difficult.
-Encouraged to ask
questions.
-
I. Discharge Plan (either METHOD OR METHODS)
Medication Health teaching
04/24/2023 -adviced the patient to Take the full course of

antibiotics as prescribed by your healthcare
.Cefixime 200mg/tab 2x a day for 7days (8 am- provider. Make sure to follow the instructions
6 pm) regarding dosage and duration.
. paracetamol 500 mg/tab 1 tab every 4 hours -Discussed every medication's side effects and
for fever how to manage when experienced
-Adviced the patient not to stop taking them

just because she feel better not finishing the
medication make the infection comeback it
43
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may also make future infection harder to treat.
-Emphasized the importance of consulting a

physician prior to taking any medication
-Instructed the importance for follow check up

on the date stated.
Exercise/environment -Emphasized the importance of hygienic

practice
-Adviced the patient activities of daily living

household chores.
-Demonstrated deep breathing exercises to

promote lung capacity and re demonstrated
by the patient.
-Allowed exercise such as walking gradually or

as tolerated.
-Encouraged patient to engage herself to have

moderate exercise
-Adviced the patient to maintain quiet and

clean environment.
Health education -Educated patient about the possible health

outcome when proper health teaching
specified for her condition is not observed.
-Emphasized the importance of full strict
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health regimen that helps boost her immune

system since the patient is prone to
opportunistic bacteria.
-Encouraged the patient to observe good

hygiene including washing hands, avoid using
irritating cosmetics or chemicals in the area of
the vagina such as strong soap
- teaching proper techniques in washing the

intimate parts like washing the vagina to anus
from front to back
- Encouraged patient to drink Plenty of Water

it is important to flush out bacteria and help in
the healing process. Drink plenty of water
throughout the day.
Diet --Adviced the patient to avoid carbonated

drinks and Limit Caffeine and Alcohol this can
irritate the bladder and worsen symptoms.
Avoid or limit the consumption of these
substances.
- Adviced the patient to avoid high fat like

dairy products, cured meats, and processed
foods and salty food
-Maintain a well-balanced diet that includes a

variety of fruits, vegetables, whole grains, lean
proteins, and healthy fats. A balanced diet
helps provide essential nutrients and supports
45
Philippines 3800
overall health.
Sexual activities -Instructed to maintain relationship with her

husband,recommended to avoid sexual
activities until the infection has been treated
and resolved.
- sexual activities should be moderate at this

time and instruct the client to void before and
after coitus; and observe proper technique in
washing the vaginal area.
REFERENCE:
Fallahian, M. (2005). Asymptomatic Bacteriuria in Users of Intrauterine
Devices. ojs3.sbmu.ac.ir. https://doi.org/10.22037/uj.v2i3.240
Gupta, K., Stapleton, A. E., Hooton, T. M., Roberts, P. L., Fennell, C. L., & Stamm, W. E. (1998). Inverse
Association of H2O2-Producing Lactobacilli and Vaginal Escherichia coli Colonization in Women with
Recurrent Urinary Tract Infections. The Journal of Infectious Diseases, 178(2), 446–
450. https://doi.org/10.1086/515635
Hooton, T. M., Roberts, P. L., & Stamm, W. E. (1994). Effects of Recent Sexual Activity and Use of a
Diaphragm on the Vaginal Microflora. Clinical Infectious Diseases, 19(2), 274–
278. https://doi.org/10.1093/clinids/19.2.274
Neumann, I. (2014). Pyelonephritis (acute) in non-pregnant women. PubMed Central

(PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220693/
46
Philippines 3800
Scholes, D., Hooton, T. M., Roberts, P. L., Gupta, K., Stapleton, A. E., & Stamm, W. E. (2005b). Risk Factors
Associated with Acute Pyelonephritis in Healthy Women. Annals of Internal Medicine, 142(1), 20.
https://doi.org/10.7326/0003-4819-142-1-200501040-00008
Scholes, D., Hooton, T. M., Roberts, P. L., Gupta, K., Stapleton, A. E., & Stamm, W. E. (2005). Risk Factors
Associated with Acute Pyelonephritis in Healthy Women. Annals of Internal Medicine, 142(1),
20. https://doi.org/10.7326/0003-4819-142-1-200501040-00008
Svanbor, S., Irene Leijonhufvud, B.,Ragnars, D., Karpman B.,Andersson,C. 2007 Inherited
Susceptibility to Acute Pyelonephritis: A Family Study of Urinary Tract Infection Pages
1227–1234. https://academic.oup.com/jid/article/195/8/1227/818893
Scholes, D., Hawn, T. R., Roberts, P. L., Li, S., Stapleton, A. E., Zhao, L. P., Stamm, W. E., & Hooton, T. M.
(2010). Family History and Risk of Recurrent Cystitis and Pyelonephritis in Women. The Journal of
Urology, 184(2), 564–569. https://doi.org/10.1016/j.juro.2010.03.139
Scholes, D., Hooton, T. M., Roberts, P. L., Gupta, K., Stapleton, A. E., & Stamm, W. E. (2005b). Risk Factors
Associated with Acute Pyelonephritis in Healthy Women. Annals of Internal Medicine, 142(1), 20.
https://doi.org/10.7326/0003-4819-142-1-200501040-00008
Scholes D, Hooton TM, Roberts PL, Stapleton AE, Gupta K, Stamm WE. Risk factors for recurrent urinary
tract infection in young women. J Infect Dis. 2000;182:1177–82. [PMID: 10979915] [PubMed] [Google
Scholar] [Ref list] - Google Search. (n.d.). https://www.google.com/search?q=Scholes+D%2C+Hooton+TM
%2C+Roberts+PL%2C+Stapleton+AE%2C+Gupta+K%2C+Stamm+WE.
+Risk+factors+for+recurrent+urinary+tract+infection+in+young+women.+J+Infect+Dis.
+2000%3B182%3A1177%E2%80%9382.+%5BPMID%3A+10979915%5D+%5BPubMed%5D+
%5BGoogle+Scholar%5D+%5BRef+list%5D&rlz=1C1CHBF_enPH884PH884&oq=Scholes+D%2C+Hooton+TM
%2C+Roberts+PL%2C+Stapleton+AE%2C+Gupta+K%2C+Stamm+WE.
+Risk+factors+for+recurrent+urinary+tract+infection+in+young+women.+J+Infect+Dis.
+2000%3B182%3A1177%E2%80%9382.+%5BPMID%3A+10979915%5D+%5BPubMed%5D+
%5BGoogle+Scholar%5D+%5BRef+list%5D&aqs=chrome..69i57.749j0j7&sourceid=chrome&ie=UTF-8
Tokushukai Group. (n.d.). Tokushukai

Group. https://www.tokushukai.or.jp/en/treatment/internal/nephrology/jinujien.php
47
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Uropathogens Causing Urinary Tract Infections in Females and Their Susceptibility to Antibiotics.
(n.d.). https://www.urotoday.com/volume-4-2011/vol-4-issue-1/49330-uropathogens-causing-urinary-
tract-infections-in-females-and-their-susceptibility-to-antibiotics.html
48

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SAINT TONIS COLLEGE, INC.

(Formerly: Kalinga Christian Learning Center)

RATIONALE FOR CHOOSING THE CASE

II. Biographic Data

III. Admission Data

IV. Nursing Health History

B. Past Medical History (Other)

C. FAMILY MEDICAL HISTORY AND GENOGRAM

SAINT TONIS COLLEGE, INC.

V. PATTERNS OF HEALTH FUNCTIONING (GORDON’S FUNCTIONAL

VI. Course in the Ward (Doc Orders)

Date and Time Doctors Order Rationale Nursing Responsibilities

Secure Consent For legal purposes and to  Served as a witness

TPN every shift TPN is a nutritional solution  Maintain aseptic

ensuring that all daily  Monitored intake

DAT To maintain patient’s  Informed and

Diagnostics:  Verified doctor's

-To measure the nitrogen the exams

-To assess presence of uric

IVF: PNSS 1L x 16 For hydration and to  Verified doctor's

TF: PLRS 1L x 16 Plain Lactated Ringer's  Verified doctor's

Medications:  Verified doctor's

Paracetamol 300mg -To decrease fever administration of

V/S every 2 hours/ To obtain baseline data of  Monitored V/S

Refer For further assessment and  Referred and

VII. Physical Assessment

SYSTEM NORMAL ACTUAL INTERPRETATIO

person, place, and person, place, and

8.Reproductive No obstruction and The patient has no Common IUD side

12.Psychiatric Stable mood, healthy Stable mood, healthy NORMAL

B. Physical Assessment (Please refer to Kozier’s Physical Assessment Format)

a. SKIN Varies from light to Upon palpation the Due to changes in

b. HAIR Thick, silky, Thin silky, resilient, Normal

c. NAILS Convex curvature Upon inspection the By adopting proper

d. NECK Symmetrical and Symmetrical and Normal

e. LUNGS Symmetrical chest Symmetrical chest Normal

f. HEART Normal rate, regular No palpitation, Normal

g. PERIPHERAL Symmetrical pulse Symmetrical pulse Normal

h. BREAST Round shaped, Symmetrical, slightly Normal

i. ABDOMEN Uniform color Upon palpation No Due to fluid

j. UPPER and Equal size on both Equal size on both NORMAL

SKULL Proportional to the Proportional to the

FACE Oblong or round or Round shaped, Normal

NOSE Midline symmetrical Midline symmetrical Normal

pinkish in color, lips pinkish in color, lips

VIII. Diagnostic Procedure & Medical Management

Serum Creatinine 68.80 44 – 105 The result of the

Blood Uric Acid 232.51 155 – 357 The result of the

Hemoglobin 1.52 120 – 160 g/l The actual

Hematocrit 0.42 0.37– 0.43 The result of the

RBC Count 4.70 4.0- The result of the

MCV 89 80 – 100 fl The result of the

MCH 32 27 – 31 pg The result of the

MCHC 364 310 – 360 g/l The result of the

WBC Count 4.1 4.0 – 10 The result of the

Neutrophil 0.72 0.55-0.65 The result of the

Lymphocytes 0.24 0.25-0.35 The result of the

Monocytes 0.04 0.03-0.06 The result of the

Platelet Count 229 NB: 84- The result of the

Transparency Hazy Clear The result of the