What is Pyelonephritis?

Pyelonephritis is classified as an upper urinary tract infection. It is an inflammation of the

renal pelvis. Pyelonephritis is an infection of the kidney and the ureters, the ducts that carry
urine away from the kidneys. The alternative names of pyelonephritis are urinary tract
infection complicated, infection kidney, complicated urinary tract infection, or kidney
infection.

Organisms causes UTIs include Enterecoccus species, Proteus mirabilis, Pseudomonas

aeroginosa, Klebsiella, Enterobacter species and Escherichia coli (the most common cause of
UTIs). It is usually bacterial in origin and stems from an infection in another part of the urinary
tract, such as the bladder. Pyelonephritis can occur in anyone, although it is more likely to
occur in women.

Pyelonephritis most often occurs as a result of urinary tract infection, particularly when there
is occasional or persistent backflow of urine from the bladder into the ureters or an area called
the kidney pelvis. Pyelonephritis can be sudden (acute) or long-term (chronic). Acute
uncomplicated pyelonephritis is the sudden development of kidney. Chronic pyelonephritis is a
long-standing infection that does not go away. Pyelonephritis occurs much less often than a
bladder infection although a history of such an infection increases your risk. There is an
increased risk for a kidney infection if you have any of the following conditions: backflow of
urine into the ureters or kidney pelvis, kidney stones, obstructive uropathy, and renal papillary
necrosis

Individuals who are at high risk of

developing pyelonephritis include:

Gender

Diet

Inability or failure to empty the bladder completely

Poor hygiene

Immunosuppression

Instrumentation of the urinary tract (ex catheterization)

Inflammation or abrasion of the urethral mucosa.

Signs and Symptoms

Back pain or flank pain

Chills with shaking

Severe abdominal pain (occurs occasionally)

Pain particularly in the sides and groin

Fatigue

Fever

Skin changes (flushed or reddened skin, moist skin - diaphoresis, warm skin)

Urination problem such as burning during urination

An urgent need to urinate

Cloudy or abnormal urine color

Foul or strong urine odor

Need to urinate at night (nocturia)

Blood in the urine (hematuria)

Nausea with or without vomiting

And mental changes or confusion may be the only signs of a urinary tract infection in the elderly

Left untreated, pyelonephritis can lead to further kidney infections, scarring, chronic kidney disease, or
permanent damage. Serious infections can spread to other parts of the body, including the blood (sepsis).

Assessment and Diagnostic Tests

A physical exam may show tenderness when the health care provider presses
(palpate) the area of the kidney. Acute pyelonephritis is diagnosed through:

Blood culture - which may show an infection

Urinalysis - which is commonly reveals white or red blood cells in the urine,
other urine tests can reveal the type of bacteria that is involved, and

Intravenous pyelogram (IVP) or CT scan. An intravenous pyelogram (IVP) or

CT scan of the abdomen may show swollen kidneys. These tests can also help
rule out underlying disorders.

Additional tests and procedures that may be done include kidney biopsy,
kidney scan, kidney ultrasound, and voiding cystourethrogram.

Treatment

The goals of treatment are to control the infection and relieve symptoms. Due to the high
death rate elderly population and the risks of complications, prompt treatment is
recommended. Sudden (acute) symptoms usually go away within 48-72 hours after
appropriate treatment. Intravenous fluids, pain medications, anti-nausea medications and
antibiotics are the mainstay of therapy. In acute case, the course of treatment for antibiotics
is up to 10 to 14 days while severe infections may be given through intravenously. Patients
with severe infections or with depressed immune systems will be admitted to the hospital.

Prompt and complete treatment of bladder infections may prevent development of many
cases of pyelonephritis. Chronic or recurrent urinary tract infection should be treated
thoroughly. In preventing kidney infections by taking the following steps such as keep the
genital area clean. Wiping from front to back help reduce the chance of introducing bacteria
from the rectal area to the urethra, urinating immediately after sexual intercourse which
may help eliminate any bacteria that may have been introduced during sexual activity, drink
more fluids (64 to 128 ounces per day) which encourages frequent urination and flushes
bacteria from the bladder and drink cranberry juice in which prevents certain types of
bacteria from attaching to the wall of the bladder and may lessen your chance of infection.

Biographical Data
Name

: Patient X

Birthday

: September 30, 1980

Age

: 34

Sex : Female
Address : San Isidro, Cabangan, Zambales
Civil Status : Married
Number of Children

: 4

Religion : Roman Catholic

Nationality

: Filipino

Blood Type

: Type B, RH+

Height

: 411

Weight : 42 kgs
Date of Admission

: August 29, 2015

Time of Admission

: 3:08 PM

Chief of Complaint

: Body Weakness

Diagnosis

: Acute Pyelonephritis

History of Present Illness

Patient X was admitted in President Ramon Magsaysay

Memorial Hospital on August 29, 2015 at 3:08 PM with the
chief complaint of body weakness. She was diagnosis with
acute pyelonephritis. She is known for having fever
accompanied by headache before admission. She cannot
eat foods but 3 days after she was able to eat rice and
fruits. Four days prior to admission, still with the above
symptoms accompanied by body weakness.

Past Health History

During her childhood, she suffered from minor illness such

as fever, cough and colds. Patient X also added she had
measles and chickenpox when she was a child. She has a
complete immunization status. She has no allergies when
it comes to food or medications. She also doesnt
experience of having an accident that might endanger her
life or death. Patient X had undergone ligation last
October 31, 2014. She had UTI for 1 week before she was
admitted to PRMMH. The client is also verbalized that she
is not use to taking vitamin supplements. Right now, she is
taking medications per prescription of her attending
physicians.

Family Health History

In the mother side of Patient X, they have history of being

hypertensive, while the father suffers from Diabetes. One
of Patient X cousin from her mother side died from cancer
in which did not specify what type.

Psychosocial Health History

Patient X was not an alcoholic, smoker and a drug user in

her early years. She was a plain housewife. She loves
eating salty foods and loves drinking soda. She had no
allergies in foods and medicines.

Dietary Health History

Patient X was admitted on August 29, 2015 at 3:08 PM with

NPO diet for the first twenty four (24) hours and changed
to Diet as Tolerated.

Obstetric History
Patient

X has her menarche when she was a first

year high school student at age 12. She has a total
of 4 kids.

Physical Assessment
Body Part

Technique Used

Normal Findings

Actual Findings

Interpretation

Body Part

Technique Used

Normal Findings

Actual Findings

Interpretation

Skin
Skin color

Inspection

Light to deep brown

Deep brown

Normal

Uniformity of skin color

Inspection

General Uniformity

General Uniformity

Normal

Skin lesions
Skin moisture

Inspection
Inspection/ Palpation

Slightly moisture/ warm/ smooth

Warm/ smooth

Normal

Skin turgor

Inspection/ Palpation

Returns back to original shape

when pinched

Returns back to original shape

when pinched

Normal

Nail
Nail texture
Nail plate shape

Inspection
Inspection

Smooth Texture
Convex Curvature

Smooth
Convex

Normal
Normal

Nail bed color

Inspection

Pink to brown depends on skin

color

Light Brown

Normal

Evenly distributed

Evenly distributed

Normal

Head or Hair
Hair over the scalp

Inspection

Hair evenness

Inspection

Texture and oiliness

Inspection

Silky, Resilient hair

Silky Hair

Normal

Thickness and thinness

Inspection

Thick hair

Thick Hair

Normal

Infection and
infestation

Inspection

No infection or infestation

No infection or
infestation

Normal

Size rounded, smooth

contour
Uniform consistency, absence
of nodule
Symmetrical facial
movement
Eyes

Rounded

Normal

Uniform consistency,
absence of nodule
Symmetrical facial
movement

Normal

Skull and Face

Skull shape

Inspection/ Palpation

Skull for nodule/

masses/ depresssion
Symmetry on facial
movement

Inspection/ Palpation

Eyebrows for hair

distribution
Eyelids
Conjunction
Cornea-clarity and
texture
Pupil for color and
symmetry size
Pupil reaction to light

Inspection

Skin intact

Skin intact

Normal

Inspection
Inspection
Inspection

Lids closed symmetrical

Shiny, smooth pink or red
Transparent, shiny, smooth,
visibility of Iris
Black in color, equal in size,
flat and round
Constrict when illuminated

Normal
Normal
Normal

Reaction to
accomodation

Inspection

Dilates- far objects,

Constrict- near objects
Ears

Lids closed symmetrical

Shiny, light pink
Transparent, visibility of
Iris
Black in color, equal in
size, flat and round
Constrict when
illuminated
Dilates- far objects,
Constrict- near objects

Auricles-color
symmetry
Auricles of elasticity/
tenderness

Inspection

Same as skin color

Same as skin color

Normal

Palpation

Firm and not tender, Pinna

recoils after fold

Firm and not tender,

Pinna recoils after fold

Normal

Hearing acuity:
respond to normal
voice

Palpation

Audible

Audible

Normal

Inspection/ Palpation

Inspection
Inspection

Normal

Normal
Normal
Normal

Hearing acuity: respond to Palpation

normal voice

Audible

Audible

Normal

Hearing acuity: respond to Palpation

whispered voice

Able to identify what is heard

Able to identify what is heard

Normal

External nose for any

deviation

Inspection

Nose
Symmetric/ straight, no discharge, Symmetric/ straight, no
uniform color
discharge, uniform color

External nose for

tenderness
Patency of both nasal
cavaties

Palpation

Not tender and no lesions

Palpation

Air movement restricted in one or Air movement restricted in

both nares
one or both nares

Lips and buccal mucosa

Inspection

Teeth and gums

Inspection

Mouth
Uniform pink color

Not tender and no lesions

Brownish

Normal
Normal
Normal

Abnormal

Pinkish

Normal

Tongue/floor of the mouth Inspection

Pinkish gum, smooth white shiny

enamel
Central position

Central position

Normal

Tongue movement

Inspection

Moves freely, no tenderness

Moves freely, no tenderness

Normal

Oropharynx and tonsils

Inspection

Pink/ smooth posterior wall

Pink/ smooth posterior wall

Normal

Inspection

Neck
Muscle equality in size, head
centered

Muscle equality in size, head

centered

Normal

Coordinated smooth with no

discomfort
Lobes may not be palpated

Normal

Palpation

Coordinated smooth with no

discomfort
Lobes may not be palpated

Inspection

Thorax
Symmetrical chest

Symmetrical chest

Normal

Neck muscles

Observe head movements Inspection

Thyroid glands for
smoothness
Thorax shape from
posterior/ lateral view

Normal

Posterior thorax

Palpation

Skin intact, uniform temp

Normal

Full symmetrical chest

expansion, equal depths

Skin intact, uniform

temp
Full symmetrical chest
expansion, equal depths

Posterior chest for

respiratory excursion

Palpation

Anterior thorax for

breathing
Breath sounds

Inspection

Regular rhythm respiration

Regular rhythm respiration

Normal

Auscultations

Normal breathing sounds

Normal breathing sounds

Normal

Unblemished skin uniform

color
Rounded

Normal

Normal

Abdomen
Abdomen for skin
integrity
Abdomen for contour
and symmetry

Inspection
Inspection

Unblemished skin uniform

color
Flat, rounded, concave

Abdomen for vowels

sounds
Liver

Auscultations

Audible bowel sounds

Audible bowel sounds

Normal

Palpation

May not be palpable

May not be palpable

Normal

Equal in both sides of the

body
No swellings

Equal in both sides of the

body
No swellings

Normal

Normal

Musculo-Skeletal
Muscles

Inspection

Joints for swelling

Inspection

Each joints for

abnormalities

Palpation

No swelling/ tenderness/
nodules

No swelling/ tenderness/
nodules

Normal

Locate edema/
tenderness

Palpation

No swelling/ tenderness

No swelling/ tenderness

Normal

Contraction of biceps can

be seen or felt

Normal

Normal

Neurological
Bicep reflex

Percussion

Contraction of biceps can be

seen or felt

Tricep reflex

Percussion

Contraction of
triceps can be seen
or felt

Contraction of
triceps can be
seen or felt

Normal

Knee

Percussion

Contraction of the
quadriceps causes
knee to extend

Contraction of the
quadriceps causes
knee to extend

Normal

Ankle

Percussion

Foot jerks and moves Foot jerks and

downward
moves downward

Normal

Plantar

Percussion

Toes bend or curl

Normal

Toes bend or curl

Vital Signs

Temperature

Technique
-

Normal findings
35.6-37.7c

Actual findings

Interpretation

38.7C

Due to presence of

Pulse rate

Palpation

60-100 bpm; regular

80 bpm

infection
Normal

Respiratory

Inspection

14-20 bpm

24 bpm

Slightly Above

Rate

Normal Respiratory
rate

Blood Pressure

Palpation and

100/60-

auscultation

<120/<80mmhg

130/90 mmHg

Slightly Elevated
Blood pressure

Laboratory Procedures
A. Urinalysis
Date: August 29, 2015
Time:

Color

Normal Range

Results

Interpretation

Pale Yellow or Amber

Yellow

Normal. Colorless indicates highly diluted

and recent fluid consumption. Pale yellow
to yellow is normal. Amber colored urine
is normal and concentrated. Deep yellow
indicates riboflavin and dehydration.

Transparency

Clear to slightly hazy

Slightly turbid

Abnormal. Freshly voided urine is clear

and transparent. Cloudy urine may be
caused by crystals, deposits, white cells,
epithelial cells or fat globules or presence
of glucose.

Ph
Albumin
Sugar
Specific gravity
Blood
Ketone
Bilirubin
Nitrate
Urobilinogen

7.35-7.45

6.0

Low. May indicate diabetic ketoacidosis.

Negative.
Negative. Glycosuria generally means

1.015
normal

diabetes mellitus.
Normal.
NA.
NA.
NA.
NA.
Normal. When hemoglobin breaks down,

1.015-1.025
0-0.02

bilirubin is formed in the reticuloendothelial

cells of the spleen and bone marrow, and
transported to the liver. Urine bilirubin aids
in the diagnosis and monitoring of treatment
for hepatitis and liver dysfunction. Urine
bilirubin is an early sign of hepatocellular
disease or biliary obstruction. Urine bilirubin
is an important part of UA because bilirubin
may often appear in the urine before the
signs of liver dysfunction become apparent.

Leukocytes

Trace

A. BLOOD CHEMISTRY
Date: September 1, 2015
Time:

Normal Range

Results

Interpretation

Sodium

138-145mEq/L

138

Normal.

Potassium

3.5-5.3mEq/L

3.49

Low.

Date: September 2, 2015

Time:

Normal Range

Results

Interpretation

Fasting Blood Sugar

70-105mg/dL

120

High.

Total Cholesterol

Up to 200mg/dL

141.7

Low.

Triglycerides

35-165mg/dL

71.9s

Normal.

A. HEMATOLOGY
Date: September 2, 2015
Time:

Normal Range

Results

Interpretation

Hematocrit

36-48%

38.4%

High.

Hemoglobin

120-160g/L

128g/L

Normal.

WBC count

5.10x10g/L

12.1x10gL

High.

Neutrophils

50.0-70.0%

89%

High.

Lymphocytes

20.0-40.0%

11%

Low.

Platelet Count

150-450x10g/L

346x10g/L

Normal.

Anatomy and Physiology

A. Urinary system
The urinary system consists of the kidneys, ureters, urinary
bladder, and urethra. The kidneys filter the blood to remove wastes
and produce urine. The ureters, urinary bladder, and urethra together
form the urinary tract, which acts as a plumbing system to drain urine
from the kidneys, store it, and then release it during urination.
Besides filtering and eliminating wastes from the body, the urinary
system also maintains the homeostasis of water, ions, pH, blood
pressure, calcium and red blood cells.

Anatomy of the Urinary system

Kidneys
The kidneys are a pair of bean-shaped organs found along the posterior wall of
the abdominal cavity. The left kidney is located slightly higher than the right kidney
because the right side of the liver is much larger than the left side. The kidneys,
unlike the other organs of the abdominal cavity, are located posterior to the
peritoneum and touch the muscles of the back. The kidneys are surrounded by a layer
of adipose that holds them in place and protects them from physical damage. The
kidneys filter metabolic wastes, excess ions, and chemicals from the blood to form
urine.
Ureters
The ureters are a pair of tubes that carry urine from the kidneys to the urinary
bladder. The ureters are about 10 to 12 inches long and run on the left and right sides
of the body parallel to the vertebral column. Gravity and peristalsis of smooth muscle
tissue in the walls of the ureters move urine toward the urinary bladder. The ends of
the ureters extend slightly into the urinary bladder and are sealed at the point of
entry to the bladder by the ureterovesical valves. These valves prevent urine from
flowing back towards the kidneys.

Urinary Bladder
The urinary bladder is a sac-like hollow organ used for the storage of urine.
The urinary bladder is located along the bodys midline at the inferior end of the
pelvis. Urine entering the urinary bladder from the ureters slowly fills the hollow
space of the bladder and stretches its elastic walls. The walls of the bladder allow
it to stretch to hold anywhere from 600 to 800 milliliters of urine.
Urethra
The urethra is the tube through which urine passes from the bladder to the
exterior of the body. The female urethra is around 2 inches long and ends inferior
to the clitoris and superior to the vaginal opening. In males, the urethra is around 8
to 10 inches long and ends at the tip of the penis. The urethra is also an organ of
the male reproductive system as it carries sperm out of the body through the penis.
The flow of urine through the urethra Urinary system cross-secrion is controlled by
the internal and external urethral sphincter muscles. The internal urethral
sphincter is made of smooth muscle and opens involuntarily when the bladder
reaches a certain set level of distention. The opening of the internal sphincter
results in the sensation of needing to urinate. The external urethral sphincter is
made of skeletal muscle and may be opened to allow urine to pass through the
urethra or may be held closed to delay urination.

Physiology of Urinary Syatem

Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important internal conditions by controlling the excretion of
substances out of the body.
Ions. The kidney can control the excretion of potassium, sodium, calcium, magnesium, phosphate, and chloride
ions into urine. In cases where these ions reach a higher than normal concentration, the kidneys can increase their
excretion out of the body to return them to a normal level. Conversely, the kidneys can conserve these ions when they
are present in lower than normal levels by allowing the ions to be reabsorbed into the blood during filtration.
pH. The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate ions in the blood to control
blood pH. H+ ions are produced as a natural byproduct of the metabolism of dietary proteins and accumulate in the
blood over time. The kidneys excrete excess H+ ions into urine for elimination from the body. The kidneys also conserve
bicarbonate ions, which act as important pH buffers in the blood.
Osmolarity. The cells of the body need to grow in an isotonic environment in order to maintain their fluid and
electrolyte balance. The kidneys maintain the bodys osmotic balance by controlling the amount of water that is
filtered out of the blood and excreted into urine. When a person consumes a large amount of water, the kidneys reduce
their reabsorption of water to allow the excess water to be excreted in urine. This results in the production of dilute,
watery urine. In the case of the body being dehydrated, the kidneys reabsorb as much water as possible back into the
blood to produce highly concentrated urine full of excreted ions and wastes. The changes in excretion of water are
controlled by antidiuretic hormone (ADH). ADH is produced in thehypothalamusand released by the posteriorpituitary
glandto help the body retain water.

Blood Pressure. The kidneys monitor the bodys blood pressure to help maintain
homeostasis. When blood pressure is elevated, the kidneys can help to reduce blood pressure by
reducing the volume of blood in the body. The kidneys are able to reduce blood volume by
reducing the reabsorption of water into the blood and producing watery, dilute urine. When
blood pressure becomes too low, the kidneys can produce the enzyme renin to constrict blood
vessels and produce concentrated urine, which allows more water to remain in the blood.
Filtration
Inside each kidney are around a million tiny structures called nephrons. Thenephronis the
functional unit of the kidney that filters blood to produce urine. Arterioles in the kidneys
deliver blood to a bundle of capillaries surrounded by a capsule called a glomerulus. As blood
flows through the glomerulus, much of the bloods plasma is pushed out of the capillaries and
into the capsule, leaving the blood cells and a small amount of plasma to continue flowing
through the capillaries. The liquid filtrate in the capsule flows through a series of tubules lined
with filtering cells and surrounded by capillaries. The cells surrounding the tubules selectively
absorb water and substances from the filtrate in the tubule and return it to the blood in the
capillaries. At the same time, waste products present in the blood are secreted into the
filtrate. By the end of this process, the filtrate in the tubule has become urine containing only
water, waste products, and excess ions. The blood exiting the capillaries has reabsorbed all of
the nutrients along with most of the water and ions that the body needs to function.

Storage and Excretion of Wastes

After urine has been produced by the kidneys, it is transported through the ureters to the
urinary bladder. The urinary bladder fills with urine and stores it until the body is ready for its
excretion. When the volume of the urinary bladder reaches anywhere from 150 to 400 milliliters, its
walls begin to stretch and stretch receptors in its walls send signals to thebrainandspinal cord.
These signals result in the relaxation of the involuntary internal urethral sphincter and the sensation
of needing to urinate. Urination may be delayed as long as the bladder does not exceed its
maximum volume, but increasing nerve signals lead to greater discomfort and desire to urinate.
Urination is the process of releasing urine from the urinary bladder through the urethra and out
of the body. The process of urination begins when the muscles of the urethral sphincters relax,
allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth
muscle in the walls of the urinary bladder contract to expel urine from the bladder.
Production of Hormones
The kidneys produce and interact with several hormones that are involved in the control of
systems outside of the urinary system.

Calcitriol. Calcitriol is the active form of vitamin D in the human body. It is produced by the kidneys
from precursor molecules produced by UV radiation striking the skin. Calcitriol works together with
parathyroid hormone (PTH) to raise the level of calcium ions in the bloodstream. When the level of
calcium ions in the blood drops below a threshold level, theparathyroid glands release PTH, which in
turn stimulates the kidneys to release calcitriol. Calcitriol promotes thesmall intestine to absorb
calcium from food and deposit it into the bloodstream. It also stimulates the osteoclasts of theskeletal
systemto break down bone matrix to release calcium ions into the blood.

Erythropoietin. Erythropoietin, also known as EPO, is a hormone that is produced by the kidneys to
stimulate the production of red blood cells. The kidneys monitor the condition of the blood that passes
through their capillaries, including the oxygen-carrying capacity of the blood. When the blood becomes
hypoxic, meaning that it is carrying deficient levels of oxygen, cells lining the capillaries begin
producing EPO and release it into the bloodstream. EPO travels through the blood to the red bone
marrow, where it stimulates hematopoietic cells to increase their rate of red blood cell production. Red
blood cells contain hemoglobin, which greatly increases the bloods oxygen-carrying capacity and
effectively ends the hypoxic conditions.

Renin. Renin is not a hormone itself, but an enzyme that the kidneys produce to start the reninangiotensin system (RAS). The RAS increases blood volume and blood pressure in response to low blood
pressure, blood loss, or dehydration. Renin is released into the blood where it catalyzes angiotensinogen
from the liver into angiotensin I. Angiotensin I is further catalyzed by another enzyme into Angiotensin II.

Angiotensin II stimulates several processes, including stimulating the adrenal cortex to produce the
hormone aldosterone. Aldosterone then changes the function of the kidneys to increase the reabsorption
of water and sodium ions into the blood, increasing blood volume and raising blood pressure. Negative
feedback from increased blood pressure finally turns off the RAS to maintain healthy blood pressure
levels.

Angiotensin II stimulates several processes, including stimulating the adrenal

cortex to produce the hormone aldosterone. Aldosterone then changes the function
of the kidneys to increase the reabsorption of water and sodium ions into the
blood, increasing blood volume and raising blood pressure. Negative feedback from
increased blood pressure finally turns off the RAS to maintain healthy blood
pressure levels.
THE KIDNEYS
Kidneys are the waste filtering and disposal system of the body. As much as 1/3
of all blood leaving the heart passes into the kidneys to be filtered before flowing
to the rest of the bodys tissues.

Anatomy of the Kidney

Location
Kidneys are a pair of organs found along the posterior
muscular wall of the abdominal cavity. The left kidney is
located slightly more superior than the right kidney due to
the larger size of the liver on the right side of the body.
Unlike the other abdominal organs, the kidneys lie behind
the peritoneum that lines the abdominal cavity and are thus
considered to be retroperitoneal organs. The ribs and
muscles of the back protect the kidneys from external
damage. Adipose tissue known as perirenal fat surrounds the
kidneys and acts as protective padding.

Structure of the kidney

On sectioning, the kidney has a pale outer region- the
cortex- and a darker inner region- the medulla. The medulla is
divided into 8-18 conical regions, called the renal pyramids; the base
of each pyramid starts at the corticomedullary border, and the apex
ends in the renal papilla which merges to form the renal pelvis and
then on to form the ureter. In humans, the renal pelvis is divided into
two or three spaces -the major calyces- which in turn divide into
further minor calyces. The walls of the calyces, pelvis and ureters are
lined with smooth muscle that can contract to force urine towards
the bladder by peristalsis.
The cortex and the medulla are made up of nephrons; these are the
functional units of the kidney, and each kidney contains about 1.3
million of them.

The nephron is the unit of the kidney responsible for ultrafiltration of the blood and
reabsorption or excretion of products in the subsequent filtrate. Each nephron is made
up of:

A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as blood
is filtered through this sieve-like structure. This filtration is uncontrolled.

The proximal convoluted tubule. Controlled absorption of glucose, sodium, and other
solutes goes on in this region.

The loop of Henle. This region is responsible for concentration and dilution of urine by
utilising a counter-current multiplying mechanism- basically, it is water-impermeable
but can pump sodium out, which in turn affects the osmolarity of the surrounding
tissues and will affect the subsequent movement of water in or out of the waterpermeable collecting duct.

The distal convoluted tubule. This region is responsible, along with the collecting duct
that it joins, for absorbing water back into the body- simple maths will tell you that
the kidney doesn't produce 125ml of urine every minute. 99% of the water is normally
reabsorbed, leaving highly concentrated urine to flow into the collecting duct and then
into the renal pelvis.

Blood Supply

The renal arteries branch directly from the abdominal aorta and enter the kidneys
through the renal hilus.

Inside our kidneys, the renal arteries diverge into the smaller afferent arterioles of
the kidneys.

Each afferent arteriole carries blood into the renal cortex, where it separates into a
bundle of capillaries known as a glomerulus.

From the glomerulus, the blood recollects into smaller efferent arterioles that
descend into the renal medulla.

The efferent arterioles separate into the peritubular capillaries that surround the
renal tubules.

Next, the peritubular capillaries merge to form veins that merge again to form the
large renal vein.

Finally, the renal vein exits the kidney and joins with the inferior vena cava, which
carries blood back to the heart.

Physiology of the Kidneys

Functions
The kidney participates in whole-body homeostasis, regulating acid-base balance,
electrolyte concentrations, extracellular fluid volume, and regulation of blood pressure.
The kidney accomplishes these homeostatic functions both independently and in concert
with other organs, particularly those of the endocrine system. Various endocrine
hormones coordinate these endocrine functions; these include renin, angiotensin II,
aldosterone, antidiuretic hormone, and atrial natriuretic peptide, among others.
Many of the kidney's functions are accomplished by relatively simple mechanisms of
filtration, reabsorption, and secretion, which take place in the nephron. Filtration, which
takes place at the renal corpuscle, is the process by which cells and large proteins are
filtered from the blood to make an ultrafiltrate that will eventually become urine. The
kidney generates 180 liters of filtrate a day, while reabsorbing a large percentage,
allowing for only the generation of approximately 2 liters of urine. Reabsorption is the
transport of molecules from this ultrafiltrate and into the blood. Secretion is the reverse
process, in which molecules are transported in the opposite direction, from the blood into
the urine.

Excretion of wastes

The kidneys excrete a variety of waste products produced by metabolism. These include
the nitrogenous wastes urea, from protein catabolism, and uric acid, from nucleic acid
metabolism.
Acid-base homeostasis

Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is
the maintenance of pH around a relatively stable value. The kidneys contribute to acidbase homeostasis by regulating bicarbonate (HCO3-) concentration.

Osmolality regulation

Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which
communicates directly with the posterior pituitary gland. An increase in osmolality
causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption
by the kidney and an increase in urine concentration. The two factors work together to
return the plasma osmolality to its normal levels.

ADH binds to principal cells in the collecting duct that translocate aquaporins to the
membrane allowing water to leave the normally impermeable membrane and be
reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the
body.

There are two systems that create a hyperosmotic medulla and thus increase the body plasma
volume: Urea recycling and the 'single effect.

Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume
is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows
urea to leave the collecting duct into the medulla creating a hyperosmotic solution that 'attracts'
water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether
ADH is still present or not.

The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not
permeable to water but is permeable to NaCl. This means that a countercurrent system is created
whereby the medulla becomes increasingly concentrated setting up an osmotic gradient for water to
follow should the aquaporins of the collecting duct be opened by ADH.

Blood pressure regulation

Long-term regulation of blood pressure predominantly depends upon the kidney. This primarily
occurs through maintenance of the extracellular fluid compartment, the size of which depends on
the plasma sodium concentration. Although the kidney cannot directly sense blood pressure,
changes in the delivery of sodium and chloride to the distal part of the nephron alter the kidney's
secretion of the enzyme renin. When the extracellular fluid compartment is expanded and blood
pressure is high, the delivery of these ions is increased and renin secretion is decreased. Similarly,
when the extracellular fluid compartment is contracted and blood pressure is low, sodium and
chloride delivery is decreased and renin secretion is increased in response.

Renin is the first in a series of important chemical messengers that comprise the
renin-angiotensin system. Changes in renin ultimately alter the output of this system,
principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple
mechanisms, but both increase the kidney's absorption of sodium chloride, thereby
expanding the extracellular fluid compartment and raising blood pressure. When renin
levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading
to increased sodium chloride reabsorption, expansion of the extracellular fluid
compartment, and an increase in blood pressure. Conversely, when renin levels are low,
angiotensin II and aldosterone levels decrease, contracting the extracellular fluid
compartment, and decreasing blood pressure.

Hormone secretion

The kidneys secrete a variety of hormones, including erythropoietin, calcitriol, and renin.
Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the
renal circulation. It stimulates erythropoiesis (production of red blood cells) in the
bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of
calcium and the renal reabsorption of phosphate. Part of the
renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of
aldosterone levels.

Pathophysiology
Modifiable Factors:
Lifestyle
Nature of Occupation
Non- modifiable Factors:
Age
Sex
Heredity

Etiology
Bacteria: Escherichia Coli

Attachment of bacteria to the urethra

Proliferation of bacteria in the urethra

Urethritis

Urethrovesical reflux

Introduction of bacteria into the bladder

Proliferation of bacteria in the bladder

Inflammation of the bladder

Cystitis

Urethrovesical reflux

Introduction of the ureter

Ureteriitis

Infection ascends to the kidneys

Acute Pyelonephritis

Drug Study

Nursing Care Plan

Assessment
Subjective:

Diagnosis
Impaired urinary

"nahihirapan po ako

elimination related to desired outcome for the

Record urinary output,

flow may indicate

intervention the client was

umihi,madalas sya konti

inflammation of

investigate sudden

obstruction/

able to portray and

lang as verbalized by the

bladder mucosa as

patient.

evidence by the

appropriate for the

flow

To help maintain renal

subjective cues.

clients condition.

function, prevent infection

Encourage fluid intake up

and formation of urinary

to 3000-4000 ml per day.

stones

Frequency

Hesitancy

Instruct the client to void

Indicators of fluid

every 2-3 hours during the

balance

Vital Signs:

day and completely empty

T: 38.7

the bladder.

BP: 130/90 mmHg

Assist in maintaining

PR: 80

Dependent:

hydration/adequate

RR: 24

Administer IV fluids as

circulating volume and

indicated

urinary flow.

Objective:

Distended abdomen

Planning
Intervention
Plan of care to meet the Independent:
client.
Make a teaching plan

Rationale
Evaluation
Sudden decrease in urine After 8 hours of nursing

reduction/cessation of urine dysfunction or dehydration. verbalize improved urinary

elimination pattern.

Subjective:
"nilalamig at

Risk for

after 8 hours of

Intervention:

imbalanced body nursing intervention Monitor patient

After 2 hours of

aid in diagnosis.

nursing intervention

the client body

nanginginig po ang

temperature

katawan ko dahil sa

core temperature

Monitor

Room temperature

temperature is

lagnat koas

with normal range

environmental

number of blankets

decreased to a

temperature,

should be altered to

normal range.

verbalized by the

the client maintain temperature

Fever pattern may

patient.

Objective:

add bed linens as

indicated.

maintain near normal

body temperature.

Provide tepid sponge

Chills

baths avoid use of

May help reduce

Warm to touch

alcohol

fever

Flushed skin

Dependent:

Administer

Used to reduce

antipyretics

fever by its central

action on the

Provide cooling

hypothalamus.

Vital Signs:
T: 39.2
BP: 120/80
PR: 80
RR: 22

blankets

Subjective:

Acute pain related Plan techniques in

"Nung nakaraang

to Acute

linggo pa masakit ang inflammation of

tagiliran ko as

renal tissues as

verbalized by the
patient.

Objective:

Pain is a great sign of

After 4 hours of

which the clients level Assess the intensity

infection.

nursing intervention the

of pain will be

client was able to

location and factors that

alleviated primarily by aggravate or relieve pain.

evidenced by verbal using independent

Encourage patient to

fear that can promote

pain,guarding

verbalize concerns

relaxation and comfort.

actively listen to these

behavior,nausea and

pain

guarding behavior

diaphoresis

Plan with the

significant others to

cooperate in the pain concerns and provide

management program support by

for the client.

acceptance,remaining

Comfort and quiet

with patient and giving

environment promote

appropriate.

relaxed feeling and

permit the client to

Vital Signs:

verbalize relief of pain

reduction of anxiety or from the rate of 8 to the

resports of back side nursing interventions.

back, side and groin diaphoresis.

Independent:

Promote quiet

focus on the relaxation

T: 38.2

environment

techniques distraction.

BP:130/100

Dependent:

PR:85

Give analgesics

RR:22

according to the

Analgesics block the

treatment. .program

path of pain

rate of 3.

Course In The Ward

Date and Time
29-Aug-15
3:08 PM

Focus

Doctor's Order

Admission

Admit to medical ward

Please secure consent of

Admission

Monitor VS q 4

Nurse's Note
D Admitted a 54 years old female
due to acute pyelonephritis
Consent for admission and
management signed
Seen and examined by Dra.
Cayabyab

Monitor I & O every shift

Initial Vital Sign:

IVF: D5NM 1Lx16

1Lx16
Diet: NPO

BP: 120/ 80
PR: 89

D5LR

Lab: RBS, Serum NaK, CXR-PA

Therapeutic:

RR: 23
T: 36.7

Aminogen S 500cc infusionx16

Metoclopramide10mg/amp IV q8
PRN
Cefuroxime 750g q8
Omeprazole 4g OD
Hyosine 1g q8

3:30 PM

Post
Endosemen
t
Assessment

D
In from ER/ wheelchaired
relatrively acccompanied
Afebrile
A Placed comfortably on bed

6:00

Post
Endorsemen
t assessment

D GCS 15
A Endorsed
Diet
regimen instructed

30-Aug-15

6:00 AM

Preendorsement
Assessment

Home for request

8:00 AM

Home Meds:
Cefuroxime 50g q8
Omeprazole 4g
Hyosine 1g

Afrebrile

(-) DOB
A IVF Checked
Meds Checked
D Seen in rounds
Kept comfortable
Endorsed

31-Aug-15
6:00 AM

2:00 PM

Post
Endorsemen
t
Assessment

Nebulize q6
D Received on bed
GCS 15
(-) DOB
Afebrile
A IV patency Checked
Meds Checked
VS taken
Endorsed

Preendorseme
nt
Assessment

D
On bed
(-) Vomiting

2:15 PM

Post
Endorsemen
t Assessment

A Endorsed
D
On bed
Afebrile
(-) DOB
A IVF Checked
Meds given

1-Sep-15
6:00 AM

6:00 AM

Post
Refer to opthalmologist for
Endorsement
further evaluation and
Assessment
management Re: Infernal
strabismus
D Received patient on bed
IVF: D5LR 1L x 16 D5NM 1L x GCS 15
(-) DOB
16
Afebrile
A IV patency checked
Meds Checked
Endorsed
Post
A > Left lateral rectus palsy L
D Received patient on bed
Endorsement P > May give oral steroids if total
Assessment cholesterol and triglycerides normal GCS 15
Suggest CT-Scan
Afebrile
Suggest oral Vitamin B complex A IV patency checked
Carry out orders of Dra.
Meds Checked
Labrador
D Seen in rounds by Dr. Ramos
with new order made and carried
out
D Seen in rounds by Dr. Labrador
with new order made and carried
out
D On bed
GCS 15

6:00 AM

TBS,Total cholesterol,
Post
Endorsemen
triglycerides
Alternate eye patching
t
Assessement Vit. B complex capsule

2-Sep-15
Post Endorsement Assessment Facilitate cranial CT-Scan
(plain)
IVF: D5LR 1L x 16
D5NM
1L x 16
Give Ketorolac 30mg/amp
PRN for sevre pain

Doctor
Rounds

D Received patient on bed

GCS 15
Afebrile
(-) DOB
A IV patency checked
Meds Checked
VS Taken

Endorsed
Received patient on bed

GCS 15

Afebrile

A IV patency checked

Meds Checked
D
Seen on rounds by Dr.
Echipare
> New order made and carried

out

6:00 PM

Preendorseme
nt
Assessmen
t

D On bed
GCS 15
A Meds given

Endorsed

3-Sep-15
6:00 AM

IVF: D5LR 1L x 16
Post
Endorsement
D5NM 1L x 16
Assessment Awaiting CT-Scan result
Omeprazole 20mg OD
pre-breakfast
Prednisone 10mg/tab TID

6:00 AM

Doctor
Rounds

D Received on bed
GCS 15

Afebrile
A IV patency checked
Meds Checked
D Seen in rounds by Dr.
Ramos with new order
made and carried out

Discharge Plan
Medication
Antibiotics will treat your infection.
Prescription pain medicine can help decrease your pain. Do not wait until the pain is severe before
you take this medicine.
Acetaminophen decreases pain and fever. It is available without a doctor's order. Ask how much to
take and how often to take it. Follow directions. Acetaminophen can cause liver damage if not taken
correctly.
NSAIDs, such as ibuprofen, help decrease swelling, pain, and fever. This medicine is available with
or without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in certain people. If
you take blood thinner medicine, always ask if NSAIDs are safe for you. Always read the medicine label
and follow directions. Do not give these medicines to children under 6 months of age without direction
from your child's healthcare provider.
Take your medicine as directed. Contact your PHP if you think your medicine is not helping or you
have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins,
and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill
bottles to follow-up visits. Carry your medicine list with you in case of an emergency.

Exercise/Environment
Instruct the client on ways how to maintain the cleanliness of their environment.
Treatment
Practice Kegel exercise (only applicable in women)
Health Teaching
Ask your PHP how much liquid to drink each day and which liquids are best for you.
Do not delay urination when it is necessary. Urinate as soon as you feel the urge. This will
help flush bacteria from your urinary system. Do not wait or hold your urine for too long.
Clean your perineal (genital) area every day with soap and water. Wipe from front to back
after you urinate or have a bowel movement. Wear cotton underwear. Fabrics such as nylon and
polyester can stay damp. This can increase your risk for infection. Urinate within 15 minutes
after you have sex.
Drink more fluid 54-128 ounces. This encourages frequent urination and flushes bacteria from
the bladder.
Encourages proper food handling preparation
Do hand-washing before and after urinate

Outpatient Follow Up Care or when to contact your PHP if:

Instruct the patient to seek or return upon experience if any sign
and symptoms such as severe abdominal pain, fever, painful urination.
You have a fever after you take antibiotics for 2 days.
You have pain when you urinate, even after treatment.
Your signs and symptoms return.
You have questions or concerns about your condition or care.

Thank you!