Acute Pyelonephritis, Acute Kidney Injury
Title: Acute Pyelonephritis, Acute Kidney Injury. Scenario: A 75-year-old female with a history of asthma and type 2 diabetes mellitus began to experience burning upon urination, lower abdominal pain, and frequent urination a few days ago.
After trying to manage her symptoms by increasing fluids, she arrived at the emergency department with her daughter with complaints of right flank pain, fever, and malaise. Her daughter said that the patient who is normally alert and oriented is now experiencing some confusion. Urinalysis results show bacteriuria, hematuria, and white blood cell casts. The nurse documents the following assessment findings:
____ Temperature 102.2◦F (39◦C)
____ Heart rate = 94 bpm
____ Blood pressure = 138/76 mmHg
____ Respirations = 20 breaths per minute
____ Right sided costovertebral angle tenderness
____ Patient reports malaise
____ Reports 1 pack per day cigarette use
____ Patient not oriented to place and time
____ Patient reports nausea
Cognitive Skill: Recognize Cues
1. NGN Item Type: Extended Multiple Response
Place a check mark next to the assessment findings that require follow-up by the nurse.
Answer s:
___ Temperature 102.2◦ F (39◦C)
____ Heart rate = 94 bpm
____ Blood pressure = 138/76 mm Hg
____ Respirations = 20 breaths per minute
___ Right sided costovertebral angle tenderness
___ Patient reports malaise
____ Reports 1 pack per day cigarette use
___ Patient not oriented to place and time
____ Patient reports nausea
Rationale for your choices :
Cognitive Skill: Recognize Cues
2. NGN Item Type: Cloze
Choose the most likely options (by highlighting your choices) for the information missing from the statement below by selectin from the list of options provided.
Based on the patient’s assessment data, the nurse determines that the patient is currently at risk for complications, including _______, _______, and _______.
Options
Acute kidney injury
Lower urinary tract infection
Fluid overload
Urosepsis
Chronic kidney failure
Allergic reaction
Hypoglycemia
Septic shock
Rationale :
Cognitive Skill: Analyze Cues
Scenario: The patient is transferred to a medical unit 2 hours after arriving at the emergency department with an admitting diagnosis of pyelonephritis. She has a history of asthma and type 2 diabetes mellitus. The admitting nurse is assessing the patient and reviewing orders and diagnostic studies to develop a plan of care. The patient is awake, alert, and pleasant but is not oriented to place and time. She reorients easily with frequent reminding. She is complaining of pain but is not able to use the pain intensity scale. Ibuprofen is prescribed for pain every 6 hours as needed. Vital signs are temperature 101.4◦ F, pulse 100 bpm, respirations 22 breaths per minute, blood pressure 138/74 mm Hg. The patient is receiving intravenous normal saline at 100 mL/hour. A urine specimen was sent to the lab for culture and sensitivity. She is tolerating her clear liquid diet well. The nurse began an infusion of an extended spectrum cephalosporin as soon as the urine specimen was obtained and sent to the lab. The patient is voiding frequently and although instructed to do so, does not ask for assistance to ambulate to the bathroom.
1. NGN Item Type: Extended Response
Based on the patient’s current treatment plan, the patient’s priority needs will be to prevent which of the following? Select all that apply.
____Patient injury
____Pain
____Aspiration
____Constipation
____Hyperglycemia
____Urosepsis
____Skin breakdown
_____ G. Pressure wound
Rationale for your choices :
Cognitive Skill: Prioritize Hypotheses
2. NGN Item Type: Extended Drag and Drop
Indicate which nursing response listed in the far-left column is appropriate for each client question. Note that not all responses will be used.
Nurse’s Responses
Patient Questions
Appropriate Nurse’s Response for each Patient Question
“You may walk in the hallway as long as you are not feeling weak or dizzy.”
“How much longer will I have this pain in the side of my back?”
- “We can remove your IV needle as soon as you begin to feel better.”
“Why do I have to pass my water so frequently?”
- “The medications given to you through your IV are rapidly absorbed and will begin to kill the bacteria sooner than oral medications would.”
“When will this needle be removed from my arm?”
- “We are giving you a lot of fluids so that you do not become dehydrated and also to dilute your urine to help flush out the bacteria that is in your urinary system. The extra fluids cause you to pass your water frequently.”
“Will I be able to walk around in my room today?”
- “The IV needle will need to remain in your arm as long as you need to receive medications and fluids to treat your kidney infection.”
“Can I take this medicine as a pill instead of through the needle in my arm?”
- “You may only walk in your room with the assistance of one of our healthcare team members.”
- “The pain in the side of your back should go away as soon as the infection subsides.”
- “I can give you some pain medication, which would provide you with pain relief. Please notify me if you continue to have pain and I will ask your healthcare provider to increase or change your pain medication.”
Rationale for your choices :
Cognitive Skill: Generate Solutions
The patient has now been on the medical unit for 3 days. She was diagnosed with pyelonephritis on admission. Vital signs this morning: Temperature 98.8 (37.1◦C ), blood pressure 100/50 mm Hg, pulse 110 bpm, respirations 24 breaths per minute. The patient is oriented to self only but is awake and alert. Her daughter is at her bedside. The urine culture results showed enterococci, and therefore the broad-spectrum antibiotic the patient was receiving was replaced with sensitivity-guided antibiotic therapy. Abnormal serum laboratory results are as follows: WBC = 14500/mm3 (normal=5000-10000/mm3), BUN = 27 mg/dL (normal = 7-20 mg/dL), creatinine 2.0 mg/dL (normal = 0.5-1.1 mg/dL). She has now been diagnosed with acute kidney injury.
NGN Item Type: Matrix
Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient’s care at this time. Only one selection can be made for each nursing action.
Nursing Action
Indicated
Contraindicated
Nonessential
Consult with dietician to provide a low caloric diet.
Obtain daily weights.
Medicate with ibuprofen every 6 hours as needed for complaint of pain.
Focus on providing holistic nursing care to patient.
Carefully consider the type, frequency, and dosage of the patient’s prescribed antibiotic therapy.
Assess for the presence of bowel sounds every 4 hours.
Rationale :
Cognitive Skill: Take Action
Scenario: A 75-year-old female was admitted to the hospital 3 weeks ago with a history of a urinary tract infection at home and was diagnosed with pyelonephritis upon admission. Despite treatment, her kidney infection progressed, and she developed acute kidney injury. After her antibiotic therapy was adjusted she recovered well enough to be discharged to her daughter’s home. The patient and her daughter were given discharge instructions to manage her prescriptions and health maintenance at home. She is now at the urology clinic for a 1-week follow-up appointment. Urine and blood samples were analyzed prior to her appointment. The nurse evaluates the effectiveness of actions.
NGN Item Type: Extended Multiple Response
Which of the following findings indicate effectiveness? Select all that apply.
_____ 1. The patient reports that she wipes front to back after urinating
_____ 2. The urinalysis report shows WBC >5/hpf (high), RBCs >4/hpf (high)
_____ 3. The patient reports that she drinks 4-5 glasses of fluid per day.
_____ 4. The patient voids approximately 3 times a day.
____ 5. The patient reports that she has stopped taking her antibiotic medication since she is now feeling “fine.”
_____ 6. The patient reports no flank pain.
_____ 7. Serum creatinine level is 1.0 mg/dL.
_____ 8. The patient states that she rests frequently.
Rationale for your choices :
Cognitive Skill: Evaluate Outcomes
