Harding: Lewis’s Medical-Surgical Nursing, 11th Edition NGN Case Study 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 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 1. NGN Item Type: Extended Multiple Response Place a check mark next to the assessment findings that require follow-up by the nurse. Copyright © 2023 by Elsevier, Inc. All rights reserved. NGN Case Study 17-2 Answers: ___ 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 Cognitive Skill: Recognize Cues Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1025, 1028, 1029. 2. NGN Item Type: Cloze Choose the most likely options 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 Copyright © 2023 by Elsevier, Inc. All rights reserved. NGN Case Study 17-3 Chronic kidney failure Allergic reaction Hypoglycemia Septic shock Cognitive Skill: Analyze Cues Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1026, 1028, 1029; Ch. 46, p. 1061; Ch. 48, pp. 1132, 1133. 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 Copyright © 2023 by Elsevier, Inc. All rights reserved. NGN Case Study 17-4 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. A. ____Patient injury B. ____Pain C. ____Aspiration D. ____Constipation E. ____Hyperglycemia F. ____Urosepsis G. ____Skin breakdown Cognitive Skill: Prioritize Hypotheses Reference: Harding et al., 11th ed., 2020, Ch. 45, pp. 1026, 1028, 1029, Ch. 48, pp. 1132, 1133. 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 1. “You may walk in the hallway as long as you are not feeling weak or dizzy.” 2. “We can remove your IV needle as soon as you begin to feel better.” 3. “The medications given to you through your IV are rapidly absorbed and will begin to kill the bacteria sooner than oral medications would.” 4. “We are giving you a lot of fluids so that you do not become “How much longer will I have this pain in the side of my back?” “Why do I have to pass my water so frequently?” “When will this needle be removed from my arm?” “Will I be able to walk around in my room today?” Copyright © 2023 by Elsevier, Inc. All rights reserved. Appropriate Response for each Question NGN Case Study 5. 6. 7. 8. 17-5 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.” “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.” “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.” “Can I take this medicine as a pill instead of through the needle in my arm?” Cognitive Skill: Generate Solutions Reference: Harding et al., 11th ed., 2020, Ch. 5, pp. 70–71, Ch. 45, p. 1029. Scenario: 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 Copyright © 2023 by Elsevier, Inc. All rights reserved. NGN Case Study 17-6 (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’s 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. Cognitive Skill: Take Action Reference: Harding et al., 11th ed., 2020, Ch. 44, p. 1012, Ch. 46, pp. 1060, 1064– 1065. 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 Copyright © 2023 by Elsevier, Inc. All rights reserved. NGN Case Study 17-7 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. Cognitive Skill: Evaluate Outcomes Reference: Harding et al., 11th ed., 2020, Ch. 44, p. 1017, Ch. 45, pp. 1028, 1030, Ch. 46, pp. 1049, 1065. Copyright © 2023 by Elsevier, Inc. All rights reserved.