Nursing Case Study: Acute Pyelonephritis and Recurrent UTI Management in Gloria Johnson NUR4018

Glorias Situation

Gloria Johnson, a 47-year-old woman has a history of recurrent Urinary Tract Infections (UTIs). She has symptoms of pyelonephritis which includes chills, high fever, dehydration, dysuria, vomiting, intense right-sided flank pain, & mild hypertension. Her vital signs results contain elevated blood pressure (BP), heart rate & respiration rate with significant pain. Gloria has been feeling fatigued for 3 days. She is excreting minimal urine, along with urethra inflammation. She lives with her family. She works in a full-time demanding job which could be a potential reason for her low water intake and this may lead to recurrent UTIs. Gloria needs immediate medical assistance & treatment to manage her UTI & to reduce her pain.

Collect Cues

Gloria has been diagnosed with pyelonephritis. She has shown the symptoms of 39.2C high fever with chills, severe flank pain on her right side lower back, dry mouth, nausea, dysuria, & fatigue. These symptoms suggest that Gloria may have acute E. coli bacterial renal infection & she requires urgent intervention to avoid further problems such as sepsis or renal damage. Her medical history reveals recurrent UTIs, an influencing factor for pyelonephritis due to repetitive bacterial infection from the urinary tract to her kidneys. The resultant pathophysiology needs urgent antibiotic therapy to treat her and reduce the risk of recurrent infections in the future. Gloria's vitals show elevated BP (145/90 mmHg), tachycardia (110 bpm), increased breathing rate (22 breaths per minute), & signs of dehydration. These findings require optimal fluid management to improve her renal perfusion & to support her cardiovascular stability during the treatment. Pain assessment and management are also important in the case of Gloria as she reports severe pain (8/10) in her lower back that impacts her comfort. She requires appropriate pain-relieving medicines to ease her pain.

More laboratory tests like urinalysis for bacterial presence & blood culture tests to identify causative organisms are required for selecting antibiotics based on the sensitivity test (Alateeq, et al., 2024). Her current medications include Lisinopril 10 mg daily to treat her hypertension, and she also finished a full course of Trimethoprim-Sulfamethoxazole 8 days ago to treat UTI. The recent completion of trimethoprim-sulfamethoxazole indicates improper clearance of the prior infection or antibiotic resistance. It is important to take care if there are any possible side-effects of lisinopril drug on her renal function. Additionally, timely monitoring of urine output & renal function through laboratory tests will inform Glorias condition and ongoing management and ensure treatment efficacy.

Processing

In Gloria Johnson's case study, several abnormal details in her history and health data provide crucial insights into her current condition, guiding the development of hypotheses and potential problems. Abnormal details in Gloria's history and health data include symptoms suggesting pyelonephritis, hypertension, tachycardia, etc. Glorias pathology results show an elevated leucocyte count (15,000 cells per microliter) and an elevated CRP level of 220 mg/L confirming that bacterial infection is severely affecting her kidneys. The pain score of 8/10 indicates severe discomfort, emphasizing the urgency of pain management. As Gloria has a persistent history of recurrent UTIs and mild hypertension, it leads to pyelonephritis by allowing pathogens to ascend from the lower urinary tract to her kidneys. Hypertension is noteworthy as it impacts treatment decisions, particularly concerning antibiotic selection to avoid drugs that could exacerbate her blood pressure. Her oxygen saturation level is normal (97% on room air). Some irrelevant details can be avoided that including minor complaints which is not related to her infection and may not impact her health.

The most critical information that may not be avoided in the case of Gloria is acute symptoms of fever, severe flank pain, dry mouth, recurrent UTIs, hypertension, and tachycardia. These details will properly guide in further diagnosis and making treatment plans. Possible gaps include exposure to possible infection sources, recent travel, and a thorough medical history. Gloria's less water consumption, approximately only 2 glasses of water per day is one of the main reasons for her dehydration. Gloria's acute pyelonephritis condition worsens due to repetitive UTI recurrence and possibly because of insufficient fluid intake. Belyayeva et al. (2018), in their study, also mentioned similar symptoms of acute pyelonephritis including high fever, chills, severe flank pain, nausea, etc. as reported by Gloria's clinical presentation. Miss Johnson's case report aligns with the study and provides a thorough understanding of the clinical signs and symptoms, and treatment approaches of acute pyelonephritis (Belyayeva et al., 2018).

Gloria's condition, symptoms & hypertension need to be kept in mind for careful selection of antibiotics and other medications to prevent harmful side effects of the drugs that could raise her blood pressure. Various studies indicate that untreated or recurring urinary tract infections can cause pyelonephritis, as bacteria from the urinary tract can spread to the kidneys (Johnson et al., 2018), (Kidney Health Australia, 2018). Many researchers also highlight the significance of timely identification of the illness and administration of a suitable drug to avoid sepsis, kidney failure, or other severe consequences (Herness et al., 2020) (Jardine et al., 2019).

Identifying Problems

Acute Nursing Problem/Issue:

One acute nursing problem in the case of Gloria Johnson is acute pain related to pyelonephritis. Gloria experiences intense pain 8/10 near her lower back, just below her ribs on her right side. She finds it very difficult to be comfortable and to function because of this pain. Gloria needs to be comfortable, but she also needs to be able to participate in her treatment & recovery. To provide quick relief to Gloria, nursing treatments would involve giving her analgesics as directed by the medical practitioner, monitoring her pain frequently, and putting non-pharmacological pain management techniques into practice.

Potential Nursing Problem/Issue:

A potential nursing problem in Glorias case is the need for timely fluid intake management. Gloria reports minimal water intake, approximately 2 glasses daily, which is likely contributing to her recurrent UTIs and current pyelonephritis. This dehydration can exacerbate her condition, impair renal function, and compromise cardiovascular stability. Nursing interventions would involve closely monitoring Gloria's fluid intake and output, assessing signs of dehydration (such as dry mouth and decreased urine output), educating Gloria and her family on the importance of adequate hydration, and initiating intravenous fluids if necessary to restore and maintain fluid balance.

Establish Goals

SMART Goal for Acute Nursing Problem (Acute Pain):

Specific: By the end of my shift, Gloria will report a reduction in flank pain from 8/10 to 3/10 on the pain scale.

Measurable: Pain will be assessed using a numerical rating scale (NRS) every 4 hours.

Achievable: Administer pain medication as prescribed by the healthcare provider and provide non-pharmacological pain relief measures such as positioning for comfort, heat therapy, and distraction techniques.

Realistic: The goal is realistic as pain management interventions are within the nurse's scope of practice and align with Gloria's treatment plan.

Timely: The goal will be achieved within the shift, with ongoing assessment and adjustments made as needed to maintain comfort.

SMART Goal for Potential Nursing Problem (Risk for Fluid Volume Deficit):

Specific: By the end of my shift, Gloria will maintain adequate hydration as evidenced by consuming at least 1500 ml of fluid orally.

Measurable: Monitor and document oral intake of fluids every 2 hours.

Achievable: Educate Gloria and her family about the importance of hydration, and encourage her to drink fluids regularly. Offer fluids that Gloria prefers and find convenient to drink.

Realistic: The goal is realistic given the nurse's ability to monitor and encourage fluid intake during the shift and considering Gloria's capacity to understand and comply with recommendations.

Timely: The goal will be achieved by the end of the shift through consistent encouragement and monitoring of fluid intake.

Take Action

Implementation of evidence-based nursing interventions is necessary to offer the relevant treatment according to Gloria's needs & goals. Based on the patients condition, the healthcare workers can improve her illness and promote recovery from pyelonephritis. To improve her overall health outcomes, continuous and timey assessment, diagnosis, and proper treatment care plan is essential. To properly attend to Gloria's severe pain, nursing treatments are intended to improve her comfort level and offer prompt relief. First, nurses can precisely assess Gloria's pain by utilizing recognized pain scales, like the NRS, frequently. Potvin et al. (2024), stated the importance of frequent pain score monitoring that positively facilitates ongoing treatment modifications & better intervention. Pharmacological therapies entail giving patients analgesics in accordance with their doctor's prescription. Gloria's pain threshold and medical history are taken into consideration while selecting medications, which are designed to minimize side effects and provide sufficient pain relief. Ong (2020), in his systematic review, showed many key studies of antibiotic therapy for complicated urinary tract infections & pyelonephritis. The author also demonstrated the antibiotic therapy-associated adverse effects which provides a vast knowledge to select personalized medication to treat Gloria. To guarantee Gloria's safety and comfort, it is necessary to keep an eye on the adverse effects of medications like breathing problems, digestive problems, hypertension, tachycardia, etc. Methods like heat therapy can give relief to Gloria by applying a heating pad or warm compress to the affected pain area. It will ease the muscle tension and lessen the experience of pain. To further improve pain relief and provide relaxation, helping Gloria find a comfortable lying position to release the pressure on her flanks may help her.

Fluid monitoring & fluid intake encouragement are essential for Glorias recovery and to avoid UTI recurrence in the future. Proper monitoring and documentation of patients fluid intake in every 1-2 hours is a good strategy. Encouraging the patient to consume at least 1.5L of fluids orally by the end of the shift helps to maintain the adequate hydration levels of the patient. Cheering the patient to drink fluids she enjoys and finds convenient can help her meet her hydration goals. Early identification of fluid imbalances is made possible by routinely checking for symptoms of dehydration, such as dry mouth, decreased urine production, and changes in urine colour (Reddy et al., 2024). Timely reporting of these points to the medical practitioner or the nursing staff enables quick measures like providing IV fluids to maintain & restore hydration. It is crucial to educate patients and their families about the value of staying hydrated when managing pyelonephritis and avoiding UTIs. Strategies to boost daily fluid consumption can be discussed with the patient and the family like carrying a water bottle, making hydration goals, and keeping an eye on the colour of urine to determine the level of hydration. Ashraf et al. (2020), in their study illustrated about the importance of being hydrated everyday to avoid UTI and other renal-related issues. The authors also demonstrated about the role of cranberry juice as a home remedy to prevent UTIs and to inhibit E. coli bacteria (Ashraf et al., 2020).

Evaluate

Our goal is to decrease Gloria's pain level from 8/10 to 3/10. Pain management can be done via routine evaluations, appropriate medication keeping her other health conditions in mind, and using non-pharmacological methods like heat therapy or light exercise. Proper education and encouraging hydration to raise her oral fluid intake to at least 1500 ml of fluid intake will also help in Glorias recovery. These nursing care strategies would be effective in treating Gloria as these measures are anticipated to greatly improve Gloria's comfort, improve her hydration status, and assist the recovery of her renal function. Hudson and Mortimore (2020) demonstrated the positive effect of patient education and encouraging UTI patients to have fluid intake leads to fast recovery. Morey et al. (2021), in their study, reported the effective strategies of nursing management in the case of acute pyelonephritis.

Reflect

After considering Gloria Johnson's case study, I've identified several areas in which I need to enhance and refine my work. First, to guarantee prompt modifications to pain management techniques, I determined that there was a need for more regular and thorough pain assessments. Second, even though efforts were made to promote fluid intake, assessment accuracy might be improved by using a more systematic method of tracking and recording fluid intake. Furthermore, I noticed how critical it is to include evidence-based practices more thoroughly in my professional nursing initiatives, especially when it comes to renal disease and urology nursing. The completion of this case report reaffirmed the importance of holistic treatment in the management of difficult diseases such as pyelonephritis.

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