y An inflammation of the renal parenchyma & collecting system including the renal pelvis. The most common cause of bacteria infection, but fungi, protozoa or viruses sometimes infect Nursing Care the kidney.
Admitting Diagnosis Diagnosis:: Pyelonephritis CKD (chronic kidney disease)
Vital signs q4h Foley present –measure I&O (notify MD if urine output >60 mL in 8 hours) Weigh daily @ 5AM Peripheral IV: left FA, 20 gauge Activity as tolerated with assistance(fall assistance(fall risk) Patient has exhibited mental status changes Tx for pain
Diet Renal deficiency diet
Nursing Dx: Ineffective therapeutic regimen Impaired urinary elemination Risk for falls Acute Pain
Education Involve patient’s spouse (Greg) Teach about proper diet Teach pt about the importance of hydration
Discharge To Home
HPI/Diseases: Hx of UTI’s CKD (chronic kidney disease) Primary HTN Kidney Transplant in March 2006
Molly Johnson 10/27/2011
Medication
Room: E854 Patient: Hugnkiss, Amanda Age: 42 yrs old old Allergy: Amoxicillan, Sulfa Weight/height: 139 lbs; 5’10 Code status: Full code code Advanced directive: In chart Res/MD: McDreamy, Micah (801)403-2132 Admit: 10/26/2011@ 2300 Chief Complaint: R flank flank pain Precautions: Falls risk d/t meds
Psychosocial Hx: Father –A/W CHF Mother –deceased Liver Ca
Social Hx: Married- (Greg) Homemaker Three kids ages10, 8, 3 LDS No Hx of cigarette
Acetaminophen 650 mg PO Fever and Pain q6h prn *skin rash, hives, bleeding, n/v, loss of appetite, appetite, swelling in abd Vancom Vancomyci ycin n 15mg 15mg/kg /kg IV q12h q12h Kidne Kidney y Infection *Hypotension, *Hypotension, bitter tatse, n/v, chills, rash (redman), (redman), ototoxicity Pyridium 200 mg PO TID Analgesic, pa pain *HA, n/v, vertigo, rash, pruritus, discolors urine Norco 5mg 1 to 2 tab PRN Pain q6h *HA, dizziness, n/v, sore throat, SOB, fast
Labs/Diagnostics UA Clean Catch w/ Cx & S ordered 10/27/11 @ 1600 CT w/ Contrast done on admit 10/26/11 @ 2335 results pending Ultrasound done 10/27/11 @ 1620 results pending
Lab ValuesHCT 40 (38%46%)WBC22.7H (4.3 - 10.8 x 109 cells/L)BUN45 cells/L)BUN45 H(6 to 21 mg/dL)Creatinine2.7 H(0.6 to 1.2 mg/dL)Vanco Trough17 (1520mg/L)Hgb14.9 (12.0-15.5 g/dL)Cya (Cyclosporin)195 (150 to 300 ng/ml)