Comprehensive History: Biographic Data: Name: Date : June 22, 2009 Time of Admission 2:00 am Unit/Room: female medical

al ward1 Address: Sabang Baliuag,Bulacan Age: 25y/o Gender: Female S t a : M a e d C C i t i z F i l i p h d a t e : J 2 7 , 1 9 8 4 B : B a l i u a n A t t e n d i n K a t i p u n a n D s i s : e PyelonephritisC h C o m p l a i

t r a e i a i r n n t n o u h s

u r o h B a l i i r

s i i p r y c c o e t : c

t h p l a g , B u l a g P h y s i c i a n : D r a . i a g n A c u t i e f n t : F e v e r a

A. Past Health History During her childhood, she suffered from minor illness such as fever, cough and colds.She has a complete immunization status.She has no allergies when it comes to food or medications.She also doesnt experience of having an accidentthat might endanger her life or death.The client also verbalized that she is not use totaking vitamin supplements. Right now, she is takingmedications per prescription of her attending physician. B. History of Present Illness: The client is admitted on June 22, 2009 because of acute pyelonephritis. She is knownfor having fever and accompanied byheadache.F o u r d a ys p r i o r t o a d m i s s i o n , s t i l l w i t h the above symptoms accompanied by bodyweakness. C. Family History: In the father side of the client, they havehistory of being hypertensive. One of her brother has experiencing hypertension b.Nutritional and MetabolicPattern Before she wasadmitted in the hospitalshe consumes food richin carbohydrates and protein. She consumes5-6 glasses of water aday. She doesnt takeany vitaminsupplements. Thefollowing is her 24hour diet recall c. Elimination Pattern

Before her hospitalization, she has adifficulty of bowel pattern. She urinatesfrequently with ayellowish color anddefecates once a daywith hard formed stool.Right now, she defecateswith soft formed stool. V. Physical Assessment B P : 1 3 0 / 9 0 m m h g P R : 1 0 5 b p m T e m p e r a t u r e : 3 8 . 3 d e g r e e s c e l c i u s R R : 2 4 b p m

ANATOMYandPHYSIOLOGYURINARYSYSTEM consists of two kidneys, twoureters, one urinary bladder,one urethra Functions of Urinary System KIDNEYS-the kidneysregulate blood volume andcomposition, help regulate blood pressure, synthesizeglucose, release erythropoietin, participate in Vit. Dsynthesis and excrete wastes inthe urine. URETERS- transport urinefrom the kidneys to the urinary bladder. URINARY BLADDER- storesurine URETHRA- discharges urinefrom the body

THE KIDNEY RENAL CORTEX- The cortex isthe outer part of the kidney. This iswhere blood is filtered.RENAL MEDULLA- where theamount of salt and water in your urine iscontrolled.RENAL CAPSULE- Smooth,transparent sheet of irregular connectivetissue that is continuous withthe outer coat of theureter.MINOR CALYX- portion of theurinary collecting system withinthe kidneythat drains one renal papilla.MAJOR CALYX- portion of theurinary collecting system withinthe kidneythat drains several minor calyces

RENAL COLUMNS- are lines of the kidney matrixwhich support the cortex of the kidney. They arecomposed of lines of blood vessels and urinary tubesand a fibrous, cortical material.RENAL PYRAMID- are conical segments within theinternal medulla of the kidney. The pyramids containthe secreting apparatus and tubules.RENAL PELVIS- This is the region of the kidney whereurine collects.RENAL PAPILLA- tip of renal pyramid projecting intoa minor calyxURETERmuscular tube that serves as the duct of thekidney to carry urine to the bladder Urine Formation Glomerular filtrationTubular Reabsorption,Tubular Secretion Urine Elimination Increased bladder pressureTransmit nerve impulsePropagate to micturition Center Trigger micturition reflexContraction of the detrusor muscleAnd Relaxation of the internal urethral sphincter Urination

Non modifiable risk factors Gender Modifiable risk Factors High salt dietHabit of holding back of urine Ascending infection of the urinary tract(Escherichia coli Infection reaches pelvis and kidney interstitial abscesses present in the parenchyma Renal tubules are damage by exudates Inflammation of renal pelvis and kidney Acute Pyelonephritis Fever, chills Low back pain, flank pain Nausea, vomitingWeakness

Dysuria, Frequency

Drug Study ParacetamolMetoclopromideCeftriaxone

DISCHARGE PLAN MEDICATION-Strict compliance to medication regimen-Antibiotics for 7 days (Ceftriaxone 10 mg)EXERCISE/ENVIRONMENT-instruct the client on ways hoe to maintain the cleanliness of her environment.TREATMENT-practice kegel exerciseHEALTH TEACHING-Keep the genital area clean by wiping from front to back, it helpsreduce the chance of introducing bacteria from the rectal area to the urethra.-Drink more fluid 64-128 ounces. This encourage frequent urination andflushes bacteria from the bladder.-Encourage proper food handling preparation.-Do handwashing before and after urinate.-Do not delay urination when it is necessaryOUTPATIENT FOLLOW UPCARE-Instruct the patient to seek or return upon experience if any sign andsymptoms such as severe abdominal pain, fever, painful urination