II.

NURSING ASSESSMENT
1. PERSONAL HISTORY
Name: EJS
Age: 54
Sex: Female
Religion: Roman Catholic
Name of Parents:
Father: DJ
Mother: LJ
Address: 0390 Calachuchi St. San Antonio Manibaug Panalaya, Porac,
Pampagnga
Date of Birth: November 15, 1962
Place of Birth: Lubao, Pampanga
Nationality: Filipino
Chief Complaint: Fever, Malaise, Dysuria, Flank pain and Vomiting
Date of Admission: January 29, 2016
Admitting Diagnosis: Acute Pyelonephritis, electrolyte imbalance, anemia of
unknown etiology
2. FAMILY HISTORY
a. Size of the family
The patient has three children all of which are married.
b. Living condition
Patient EJS is a housewife, residing in their own house and their familys
major source of income is from tricycle service.
c. Socio-cultural factors
The patient and her family has a strong belief in albularyo
d. Family Health Illness History
Father: (+) Asthma
3. HISTORY OF PAST ILLNESS
The patient was previously admitted due to Cerebrovascular Accident last
November 2015.
4. HISTORY OF PRESENT ILLNESS
a. Chief Complaint: Fever, Malaise, Dysuria, Flank pain and Vomiting
b. Sequence of the appearance of signs and symptoms:
4 days prior to admission patients first episode of fever was noted.
2 days prior to admission patient had high grade fever but did not seek
consultation.

Few hours prior to admission the patient experienced two episodes of

vomiting.
At 8:30pm of January 29, 2016 the patient was admitted.
5. PHYSICAL EXAMINATION
III. ANATOMY AND PHYSIOLOGY

The renal system is composed of the kidneys, ureters, bladder and the urethra as
illustred in the image above. The urethra is tubular structure where urine, and semen in
males, moves from the bladder and out of the body. The urethra is also notably shorter
in females than in males. The bladder is an organ where urine is temporarily stored
before it leaves the body. Its caudal end opens to the urethra and its cephalic end
attaches with the two ureters. The ureter is a tubular structure wherein the urine passes
from the kidneys to the bladder.
The kidneys are the major organ of the renal system. It is responsible for various
physiologic processes such as:

excretion of metabolic wastes

regulation of fluid and electrolyte balance
regulation of arterial blood pressure
acid-base balance
regulation of RBC production
regulation of Vitamin D production
gluconeogenesis
The structural and functional unit of the kidney is the nephron. These nephrons

are rich in blood supply and are highly oxygenated. The nephrons are responsible for
the filtering mechanism of the kidneys. Blood passes through these nephrons and waste
are removed from the blood before returning to the circulation. Electrolytes and water
are also excreted or reabsorbed depending on the persons requirement.
IV. PATIENT and ILLNESS
a. Pathophysiology
b. Definition of the Disease
Acute Pyelonephritis is a condition wherein the kidneys become
inflammed due to an infection which may result to permanent kidney damage,
and can even life-threatening. Acute Pyelonephritis results from bacterial
invasion of the renal parenchyma. It is most often a result of an infection of
the lower urinary tract.
c. Synthesis of the Disease
c.a Risk Factors (Patient Based)
- Female Anatomy

- Age (Elderly)
c.b Signs and Symptoms (Patient Based)
- Fever
- Vomiting
- Cloudy urine
- Malaise
- Flank pain
- Chills
- Dysuria