Question

A. PYELONEPHRITIS A patient consulted in the emergency department with complaints of high fever, chills, dysuria, and back pain. Laboratory results are as follows: WBC – 13,000 cells/mcL Neutrophils – 10,000 per mm3 Lymphocytes – 3,500 per mm3 Serum Sodium – 136 mEq/L Serum Potassium – 3.7 mEq/L Urinalysis: Color: Hazy yellow Bacteria: Too many to count Pus cells: >100 cells/hpf RBC: >100 cells/hpf Specific gravity: 1.280 The doctor ordered co-trimoxazole (Bactrim) 800/160mg tablet TID for 14 days and phenazopyridine (Pyridium) 200 mg tablet TID for 3 days. Given the above case, answer the following questions: 1. What laboratory values point towards the diagnosis of Pyelonephritis? 2. What is the most common causative agent of urinary tract infections? 3. Give at least two (2) health teaching points that will help the prevention of recurrence of UTI? 4. Create a drug study for the medication: CO-TRIMOXAZOLE specifying the following: a. Drug classification b. Mechanism of action c. Indication (*for the case of the patient mentioned above) d. Contraindication e. Side effects f. Nursing Considerations 5. Create a drug study for the medication: PHENAZOPYRIDINE specifying the following: a. Drug classification b. Mechanism of action c. Indication (*for the case of the patient mentioned above) d. Contraindication e. Side effects f. Nursing Considerations A. GLOMERULONEPHRITIS A patient with cleft lip and bronchial asthma was brought to the emergency department with chief complaint of low-grade fever, puffiness of the face and eyes in the morning, +2 edema on both feet, and tea-colored urine. Urinalysis revealed numerous RBC and certain degree of proteinuria and Antistreptolysin-O titer reaches more than 300 todd units. The doctor came up with the diagnosis of Acute Glomerulonephritis (AGN). Answer the following questions: 1. What history-taking question should be asked by the nurse to strengthen the diagnosis of AGN? 2. Explain the pathophysiological tracing on the development of AGN. 3. The doctor ordered hydrocortisone TIV, create a drug study specifying the following: a. Drug classification b. Mechanism of action c. Indication (*for the case of the patient mentioned above) d. Contraindication e. Side effects f. Nursing Considerations B. RENAL CALCULI An elderly patient with osteoporosis consulted in an Out-patient Department with complaints of severe lower back pain. She is taking 1000 mg of calcium carbonate once a day and reports of poor hydration due to her mobility problems. Ultrasound of the Kidneys, ureters, and bladder reveal several calculi in both kidneys and is counselled to be a candidate for nephrolithotomy. Answer the following questions: 1. What pertinent data in the patient’s history may have contributed with the development of renal calculi, defend your answer? 2. Identify three (3) priority nursing diagnoses in relation to the patient’s condition and create a hypothetical Nursing Care Plans for each nursing diagnosis. 3. Identify at least two (2) health teaching points on the prevention of recurrence of renal calculi for the patient. C. RENAL FAILURE A patient with uncontrolled Type 2 Diabetes consulted in the emergency department due to shortness of breath, bipedal edema, palpitation, and decreased urinary output during the past 2 days. The following laboratory test values are presented: Serum Creatinine – 2.5 mg/dL BUN level – 30 mg/dL Serum potassium – 5.9 mEq/L HBA1C – 8% A diagnosis of Acute Renal Failure secondary to DM Nephropathy was made by the doctor. Sodium polyesterene sulfonate (Kayexalate) was ordered to normalize potassium level. Oral hypoglycemic agents were revised, and insulin therapy was started to manage the blood sugar level. Urine output is closely monitored for possible hemodialysis. Answer the following questions: 1. Explain the relationship of diabetes mellitus on the development of acute renal failure using a flow chart. 2. Identify three (3) nursing diagnoses pertinent to the patient’s condition and create hypothetical Nursing Care Plans (NCPs) for each nursing diagnosis. 3. Create a drug study for the medication: SODIUM POLYESTERENE SULFONATE specifying the following: g. Drug classification g. Mechanism of action h. Indication (*for the case of the patient mentioned above) i. Contraindication j. Side effects k. Nursing Considerations

Answer 1

PYELONEPHRITIS Case

1. Urine analysis report showing presence of bacteria, increased pus cells and increased RBCs points towards the diagnosis of pyelonephritis.Raised WBC count is also suggestive of infection.

2. Though UTI can be caused by fungi, gram positive and gram negative bacteria, the most common causative agent is Escherichia coli (uropathogenic E coli).

3. Increasing the fluid intake improves flushing out of bacteria and also prevents further infection.

Proper voiding practices like emptying the bladder completely, maintaining hygienic care practices of genitals prevents bacterial growth.

4. Drug study- Clotrimoxazole

a. It is an antibacterial drug,comes under the drug class sulfonamides.

b. It has a bactericidal action. It blocks the biosynthesis of nucleic acids and proteins essential for bacterial growth.

c.Indication: Urinary Tract Infection in the given case (other indications includes Otitis media, bacillary desentry,toxoplasmosis)

d.Contraindications: hypersensitivity to trimethoprim or sulphonamides, folic acid deficiency induced megaloblastic anemia, renal impairment, term pregnancy and lactation.

e. Side effects: Nausea,Vomiting,Anorexia,Urticaria, Hyponatremia,Aplastic anemia

f.Nursing consideration: Assess the symptoms and evaluate the therapeutic response, rule out pregnancy by asking about LMP before administering to women of child bearing age, advice to discard outdated medication and to complete the course of medication.

5. PHENAZOPYRIDINE

a. Drug classification: Analgesic (oral urinary analgesic)

b.Mechanism of action: PHENAZOPYRIDINE HCL is excreted through urine and it exerts a topical analgesic effect on the mucosal linings of the urinary tract.

c.Indication: releives symptoms due to irritation of urinary tract including pain,burning micturation, increased frequency and urgency of micturation

d.Contra indications: hypersensitivity to Phenazopyridine hydrochloride, Renal problems, liver disease or blood disorders

e.Side effects: dizziness, headache, GI disturbances

f.Nursing considerations: Educate the patient that this drug may cause reddish orange discoloration of urine

and may cause staining of clothes, advice to inform if skin discoloration, rashes or excessive fatigue occurs.

GLOMERULONEPHRITIS case

1. History about changes in urine characteristics color of urine, stream of urine. Hematuria in AGN is described as coke/tea/smoky colored urine. In AGN color of urine may be same throughout the stream.Ask about presence of other urinary symptoms like dysuria. AGN may not cause painful urination. History should also include questions about other associated symptoms like shortness of breath,headache, visual disturbances that may all be suggestive of fluid overload or hypertension.Also previous history of streptococcal infection ,may aid in diagnosis of post streptococcal AGN.

2. Pathophysiology: Inflammation of the glomeruli is initiated by an antigen antibody reaction. It may be either due to direct action to an antigen expressed or trapped inside the glomeruli or localization of a circulating Ag-Ab complex inside the kidney.This causes activation of the inflammatory mediators leading to glomerular injury. Inflammation is characterized by proliferation of the glomerular cells and infiltration of lymphocytes or the neutrophils. Process of inflammation blocks the micro circulation inside kidney reducing the GFR and increases the nitrogenous waste products in the blood. It also causes fluid and salt retention as a result of fluid over load. This is manifested as whole body edema and can worsen to life threatening pulmonary edema and hypertension.

3. HYDROCORTISONE drug study

a. Drug classification: Corticosteroid

b.Mechanism of action: is an anti inflammatory adrenocortical steroid drug. It binds to the glucocorticoid receptor leading to the inhibition of inflammatory transcription factors and promotes anti inflammatory function. Lower doses causes anti inflammatory effect whereas higher dose acts as immunosuppressant.

c.Indication: Acute Asthma and Inflammation

d.Contra indication: hypersensitivity, systemic fungal infections,inactive TB, diabetes

e. Side effects:increased appetite, insomnia, irritability, impaired wound healing, GI disturbances

f. Nursing considerations:Assess for contraindications, advice patient to avoid exposure to persons or situations that may induce infection,advice to avoid abrupt withdrawal of drug and to consult physician for tapering and stopping the dose.

RENAL CALCULI

1. Intake of 1000mg of daily calcium carbonate and poor hydration with immobility may be the contributing factors to renal calculi. Dietary Calcium binds with dietary oxalates and is excreted through feces without getting absorbed or passing through urine as crystals. But when taken in tablet form binding with oxalates does not happen leading to excretion through urine as well as crystalization and stone formation. Poor hydration may accelerate the process of stone formation my decreasing the excretion of calcium salts through urine.Immobility may lead to urinary stasis.

2. Nursing diagnosis

• Acute pain related to cellular injury/ischemia as evidenced by patient's verbal reports of pain

Interventions:

Identify the characteristics of pain --- To determine the site of obstruction

Provide comfort measures like back massage ----Promotes comfort and relieves pain

Assist with ambulation and hydration-------improved fluid intake aids in passing of small stones through urine. Ambulation prevents urinary stasis

• Impaired urinary elimination related to irritation to the bladder by calculi

Interventions:

Record intake and output ------To closely monitor the progress

Determine the patterns of urination------ to identify the presence of urgency and frequency

Encourage ambulation -------to stimulate urinary elimination

Urinary catheterization --------if patient is unable to void with respect to intake amount, aseptic catheterization can prevent complications

• Risk for fluid volume deficit related to decreased fluid intake and distress during voiding

Interventions:

Daily weight checking------------Helps to identify development of edema

Assess associated symptoms like diarrhea or vomiting------------GI disturbances can lead to decreased fluid volume

Monitor vital signs closely----------------To identify signs of dehydration

Encourage fluid intake and administer IV fluid as per order--------------helps to maintain fluid status

3.Health education : To improve dietary intake of calcium instead of calcium supplements

Improve the fluid intake to improve hydration and elimination of excess calcium salts

RENAL FAILURE case

1. Pathophysiology (------ means leads to)

Prolonged hyperglycemia---------narrowing and obstruction of micro blood vessels in the kidney--------decreased blood circulation inside the kidneys--------decreases the GFR--------increased accumulation of albumin and nitrogenous waste products in blood------------prolonged hyperglycemia and damage to blood vessels-------------deterioration in kidney function ----------------Diabetic Nephropathy

2. Nursing diagnosis

• Fluid volume excess related to micro vascular complications secondary to diabetes mellitus as evidenced by bipedal edema, shortness of breath,palpitation and decreased urine output

Interventions:

Monitor Intake and Output------------------- Helps to closely monitor the patient's condition

Monitor weight regularly ------------------ Sudden weight gain indicates fluid retention

Monitor for signs of distress --------------- Helps to establish prompt measures to prevent complications

Monitor vital signs------------------- Fluid overload can lead to tachycardia and increased BP

Check the urine analysis reports and serum electrolytes--------these are indicators of fluid status

Consider Urinary catheterization ---------------------Provides an accurate output measurement and also prompt identification of deviation in renal function

• Altered breathing pattern related to fluid overload as evidenced by shortness of breath

Interventions:

Assess the breathing pattern -------------------- circulatory overload can lead to pulmonary symptoms

Assess the SPO2 level----------------------- To identify needs of supplemental oxygen

Provide a comfortable semi fowlers or high fowlers position --------- Promotes lung expansion

Provide psychological support ----------------- Stress may increase breathlessness

Administer Oxygen via nasal cannula --------------- Helps to maintain oxygen saturation level

• Risk for complications related to uncontrolled blood glucose levels

Interventions:

Assess the renal functions----------------A renal function test can rule out renal insuficiency related to diabetes

Perform regular foot assessment ------------- Helps to identify neuropathy in earlier stages

Perform Visual acuity tests ----------------- Diabetes may lead to visual impairment/retinopathy

Assess for presence of wounds or ulcers ---------- High blood glucose levels can lead to delayed wound healing and superimpose infections

Promote adequate personal hygiene ---------------- Prevents growth and multiplication of micro organisms

Educate about importance of regular medication intake------------ Missed doses can precipitate hyperglycemia

Educate about importance of strict diet control and medication--------- A life threatening complication of DM is diabetic Ketoacidosis that can be prevented by maintaining regular uptake of correct dose medication and diet

3.SODIUM POLYESTERENE SULFONATE

Drug class: Potassium removing agent

Mechanism of action: It releases sodium or calcium ions in the stomach and takes up hydrogen ions. In the large intestine these hydrogen ions are exchanged with potassium and then it is eliminated through stool.

Indication : hyperkalemia

Contraindication: Obstructive bowel disorders, hypokalemia

Side effects: constipation, seizure, bleeding,irregular heart beats,abdominal pain

Nursing Considerations: closely monitor ABG values, Monitor serum electrolytes and minerals. Continuous ECG monitoring is required.