Post on 03-Dec-2014
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
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
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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