University Nursing Case Study NMIH308: Clinical Reasoning Analysis

This case study analyzes a critical incident involving a patient, Mrs. Jones, admitted with flank pain, high pyrexia, and dysuria, with a history of type I diabetes mellitus and acute pyelonephritis. The assignment utilizes Levett-Jones' clinical reasoning cycle to examine the patient's condition, including symptoms such as hypotension, tachycardia, and hyperglycemia, and the progression to severe complications like sepsis. The analysis explores the patient's deteriorating condition, the nurse's observations, and the importance of clinical reasoning in identifying and addressing the issues. The assignment also reviews the pathophysiology, diagnosis, and management of acute pyelonephritis, referencing relevant literature and research, including the study by Kumar et al. (2014) and the study by Eliakim-Raz, Yahav, Paul and Leibovici (2013). Furthermore, it discusses the use of antibiotics and the impact of glycemic control on patient outcomes. The paper concludes by emphasizing the nursing considerations and the importance of applying research findings to improve patient care, especially in managing the complications of acute pyelonephritis and acute kidney injury.

Running head: CASE STUDY NMIH308
CASE STUDY NMIH308
Name of the Student
Name of the University
Author Note

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Part 1
"Levett-Jones (2017) introduced the clinical reasoning cycle as having eight stages:
look, collect, process, diagnose, plan, act, evaluate and reflect. This report will analyse the
key issues that contributed to the critical incident of the case study using the initial four
stages of Levett-Jones’ (2017) clinical reasoning cycle."
Patient situation
In the case study the patient whose name is Mrs. Jones had been admitted to local
emergency department with flank pain, high pyrexia and dysuria. Mrs. Jones had a known
history of type I Diabetes Mellitus. She had also been suffering from acute pyelonephritis.
Mrs. Jones was given intravenous antibiotic in order to manage acute pyelonephritis. Polyuria
had also been seen in Mrs. Jones. During her stay at emergency department it was reported
that her fluid output was 1.7l. Her core body temperature was 38.3 degree Celsius. The
patient had low blood pressure of around 105/60 (Hypotension). Her heart rate was around
108 (tachycardia). The patient had a normal oxygen saturation level of around 97%. Her
respiratory rate was 21 (normal). However, high blood sugar level was observed which is 9.4
mmol/L.
Cues/Information
According to the case study RN Cameron was an experienced nurse who had been
working on a 16-bed medical ward along with a newly graduated nurse RN Grace. Later
again Mrs. Jones was observed by RN Cameron and it was observed that her core body
temperature was 38.8 degree Celsius. The patient’s (Mrs. Jones) respiratory rate increased
rapidly. Respiratory rate was around 29. Tachypnoea was observed. Her blood pressure was
also reduced to 89/40 (severe hypotension). Oxygen saturation level also decreased to 95%.
Mrs. Jones was also remained polyuric throughout the night. RN Cameron stated that his all

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three patients were restless overnight (Mrs.Jones and other two male patients). Next day
morning, the morning RN observed that Mrs. Jones was pale and difficult to rouse. At that
time her core body temperature was 39.4 degree Celsius, her heart rate increased to 156 bpm
(severe tachycardia). Mrs. Jones was also suffering from severe hypotension (BP 65/36). Her
blood sugar level was around 33.4 mmol/L (Hyperglycaemia). Most notably her oxygen
saturation level dropped to 90%.
Process information
Considering all the information it can be clearly stated that the patient (Mrs. Jones)
was suffering from severe acute pyelonephritis. This is basically an ascending urinary tract
infection (observed in ascending urinary tract) caused by bacteria. It produces severe
inflammation in the kidney of the affected patient. Considering the fact that the patient had a
known history of type 1 Diabetes Mellitus, she was given Lantus and Novarapid immediately
after admission. In spite of giving these two medications to control the blood glucose level
her blood glucose level was 33.4 mmol/L.
Identification of problems/issues
As the patient was suffering from acute pyelonephritis the development of
hyperglycemia in patient is quite obvious. Elevated core body temperature, tachycardia and
tachypnea were the common symptoms in the patient suffering from acute pyelonephritis.
One of the common symptoms of acute pyelonephritis is dysuria and in severe cases it
worsened to hematuria. In the case study, it was observed that the blood pressure gradually
reduced to 89/40 from 105/60. This clearly indicated that huge amount of blood loss (may be
through urine- hematuria) occurred in the patient. As a consequence, hypovolenic shock was
developed. The hypovolemic shock in turn produced a pathological change in the body that in
turn affected the normal tissue function. As a result sepsis developed in the patient. So, acute

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pyelonephritis, hypovolemic shock and sepsis were the three cardinal features that developed
sepsis in Mrs. Jones.
Part 2
Acute pyelonephritis is one of the most common infectious diseases of the kidney.
This disease is caused due to bacterial infection. This is an ascending urinary tract infection
that spreads from the bladder to the kidneys. Symptoms of acute pyelonephritis include high
fever, nausea, hematuria, flank pain, dysuria, increase urination amount and frequency. Acute
pyelonephritis is basically of two types. Two types are: uncomplicated acute pyelonephritis
and complicated pyelonephritis. Symptoms gradually worsen and may develop dysuria,
hematuria, sepsis in the patient as the severity increases with time. Proper physical
examination is required in order to diagnose acute pyelonephritis accurately. Proper
pathological and laboratory studies are helpful for the evaluation of acute pyelonephritis.
Urinalysis must be required for the diagnosis of acute pyelonephritis (Belyayeva & Jeong,
2019). Pyuria, hematuria and proteinuria can be observed in the urine of the affected patient.
Management of complicated acute pyelonephritis can be of two types. Two types include:
outpatient and patient. Outpatient refers to the healthy, non-pregnant woman. Treatment of
acute pyelonephritis includes antibiotics, analgesics, and antipyretics. Nonsteroidal anti-
inflammatory drugs (NSAIDs) are extensively used for the treatment of acute pyelonephritis.
These NSAIDs are generally responsible for managing the symptoms (such as flank pain and
high fever) of acute pyelonephritis. Uncomplicated cases of acute pyelonephritis occur due to
presence of E. coli. Cephalosporin is the most effective treatment to manage uncomplicated
acute pyelonephritis. Treatment of complicated acute pyelonephritis is completely different.
Intravenous antibiotic treatment is required in order to manage complicated acute
pyelonephritis. Intravenous antibiotic are meropenem, piperacillin-tazobactam,
fluoroquinolones, meropenem, and cefepime (Hsu et el., 2017). In order to manage the

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symptoms of complicated acute pyelonephritis in a patient, a differential diagnosis approach
should always be taken. The most severe and serious complication in acute pyelonephritis is
emphysematous pyelonephritis (EPN). This is usually observed in patients with uncontrolled
diabetes and most commonly seen in women. Emphysematous pyelonephritis (EPN) can be
diagnosed with ultra-sound and CT scan.
Acute pyelonephritis is one of the most common complications that is observed in case of
diabetes mellitus patients. There are two type of pyelonephritis and both of the
emphysematous pyelonephritis (EPN) and non-EPN (NEPN) have adverse heakthreated
effect among the patients with Diabetes mellitus. The study of Kumar et al. (2014) tried to
examine the clinical nature, microbiological nature of the disease, prognostic factors, and
treatment related outcome of pyelonephritis among the diabetic patients. In this study,
approximately 105 patients of diabetes mellitus along with the problem ofacute
pyelonephritis were recruited as study sample and they were admitted in between July 2010
to June 2012. The patients were treated with proper antibiotics as per the result of their urine
culture. Among the overall patients, it was reported the prevalence rate of the pyelonephritis
was higher among the males than that of the female population of the study. Urine and blood
culture report were positive among the 93 and 41 patients respectively. The presence of gram
negative bacteria in the urine of the affected patients was most common. Poor glycaemic
control among the patients was positively correlated with the onset of acute pyelonephritis
among the patients. It was reported that, among the all affected patients, approximately 72.3
per cent of patients had poor glycaemic control and only 12.3 per cent of the patients had
acute nephritis in spite of having a good glycaemic control..
The use of antibiotics in case of treating the pyelonephritis patients was also stated in
the study of Eliakim-Raz, Yahav, Paul and Leibovici (2013). In this study, it was reported
that, the onset of pyelonephritis is one of the common cause of morbidity among the patients

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with diabetes type 2 mellitus. This study reported the use of antibiotic such as
fluoroquinolones or b-lactams should be restricted to short term use in order to gain
maximum outcome of this disease. On the other hand, in case of other type of urogenital
problems, antibiotics must be applied for 14 days or more.
The study of Olvera-Posada et al. (2013), also stated that, the patients with poor
glycemic control had higher chances of getting affected by acute pyelonephritis and hence the
nursing personnel should try to control the blood glucose level of the patients so that the risk
of acute pyelonephritis can be mitigated among the patients (Hsu et el., 2017). Not only that,
the nursing personnel must consider the bacterial culture result so that, proper antibiotics can
be provided to the patients as well (Belyayeva & Jeong, 2019).. The nurses should also
consider the CT scans and in literature, it is reported that the sensitivity of plain X-ray
kidneys, ureters, and bladder, ultrasound and CT scan must be considered by the nurses.
The study of Van Hook (2014) stated about the problem of acute kidney injury among
the pregnant women. It was stated that, incidents of preeclampsia and thrombotic
microangiopathies were very common among during pregnancy thus it might cause acute
kidney injury among the pregnant women. According to the study of George, Nester and
McIntosh (2015), during the pregnancy a woman has high chances of having preeclampsia
and thrombotic microangiopathies. In this regard the study of Van Hook (2014), highlighted
the fact that, both of these are causative factors of acute kidney injury among the women. On
the other hand, this study also stated that, incident of Prerenalazotemia is another common
cause of kidney injury among the pregnant women (Zarbock, Gomez, &Kellum, 2014).. This
review study mainly identified various type of AKI among the patients who were pregnant
and along with this, the management of this condition was also discussed in a brief manner.
The study findings of Triposkiadis et al. (2014) reported that the use of furosemide for the
treatment of acute kidney injury. This study finding also supported the findings of Van Hook

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(2014). On the other hand, the use of Plasmapheresis was also identified in this study.
However, this technique is not at all used in the treatment of AKI globally. The study
concluded that, the incident of AKI among the pregnant women is infrequent and thus, the
AKI among the women may cause prenatal AKI and intrinsic renal disease. The treatment
process of Acute Kidney Disease (AKI) restricts the progression of disease among the
individuals by attenuating the secondary injury (Belyayeva & Jeong, 2019).
As a nursing personnel, I must consider all the findings of the above studies and must
implement these study findings in my future practices so that I can provide the best care to
the patients with AKI. As a nursing personnel, I should consider the modern techniques of
treating acute kidney injury while providing care to the patients with this condition. The
nurse must consider the health status of the patients and thereby provide required care to the
patients as well. AS an experienced nurse RN, I should take care my patients more
efficiently. I would, using clinical reasoning cycle, diagnose patients with acute
pyelonephritis and then administer the proper medication. Therefore, it can be stated that, the
use of antibiotics the management for acute pyelonephritis among the patients with diabetes
is very effective in nature. Moreover, it is also reported in this study that, the prevention of
the progression of the disease among the patients may negatively impact the risk factors of
acute kidney injury among the patients. Hence, in my future I will take care of the severe
complications that is associated with acute pyelonephritis. These complications include sepsis
renal pus formation (develops pyuria), renal vein thrombosis, acute renal or kidney injury.
Majority of the patients had responded to the antibiotic treatments. However, the survival rate
of the EPN patients were low than that of the NEPN patients but as a registered nurses, I
would keep up the habit of practicing the patient care with complete compliance with nursing
principles. Therefore, as nursing personnel, I will use the findings of this study during the
treatment process of pyelonephritis. Proper treatment might prevent the complications of

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acute pyelonephritis and I along with my professional healthcare team, would deliver the
same. In a renal care service, I will coherently work with other members of a health care team
such as nephrologist, infectious disease specialist, urologist, and obstetrician. As the nurses
and pharmacologists play, an inadmissible role for monitoring the patient affected with acute
pyelonephritis. But nursing being an integral part of the delivered patient centered care – I
would take care of the patient signs and symptoms to take care of the patient and prevent any
complications. Patients with uncontrolled diabetes, structural as well as anatomical
abnormalities in urinary tracts always develop complicate acute pyelonephritis. The most
common Gram-negative bacteria Escherichia coli is responsible for the development of acute
pyelonephritis. In some other cases, Gram-negative bacteria such as Proteus, Klebsiella, and
Enterobacter are also responsible for the development of complicated acute pyelonephritis.
Hence, to enhance my nursing practice – I would work on my clinical knowledge and should
be able to reason the patient condition with more ease and clarity, so as not to prevent the
complications. In the future, I should be more fluent with histopatholgy reports that reflects
the complication of acute pyelonephritis and should understand the underlying
pathophysiology (necrosis of the renal parenchyma of the affected patient) and relate the care
provided with more clarity. I should consider more facts about the etiologies leading to
causation of acute pyelonephritis which is a urinary tract infection (UTI) disorder, and
clinically relate how the renal architecture of the affected patient has completely been
devastated. During initial stages, symptoms of acute pyelonephritis include high fever, nausea
and flank pain. Hence as a nurse, I should more rationally check for and correlate with other
symptoms of acute pyelonephritis (such as high fever, flank pain). Thus, considering the fact
that various treatments are there to manage acute pyelonephritis, still significant morbidity as
well as mortality cases are associated with complicated acute pyelonephritis. As a registered

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nurse, I should develop my skills to deliver a more proficient biomedical care and a
humanistic support to a patient with comorbidities and suffering at the critical state.
References
Belyayeva, M., & Jeong, J. M. (2019). Acute Pyelonephritis. In StatPearls [Internet].
StatPearls Publishing. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK519537/
Eliakim-Raz, N., Yahav, D., Paul, M., &Leibovici, L. (2013). Duration of antibiotic treatment
for acute pyelonephritis and septic urinary tract infection—7 days or less versus longer
treatment: systematic review and meta-analysis of randomized controlled trials. Journal
of Antimicrobial Chemotherapy, 68(10), 2183-2191. doi.org/10.1093/jac/dkt177
George, J. N., Nester, C. M., & McIntosh, J. J. (2015). Syndromes of thrombotic
microangiopathy associated with pregnancy. ASH Education Program Book, 2015(1),
644-648. DOI: 10.1182/asheducation-2015.1.644
Hsu, F. G., Sheu, M. J., Lin, C. L., Hsieh, Y. W., & Lai, S. W. (2017). Use of Zolpidem and
Risk of Acute Pyelonephritis in Women: A Population‐Based Case‐Control Study in
Taiwan. The Journal of Clinical Pharmacology, 57(3), 376-381.
https://doi.org/10.1002/jcph.815
Olvera-Posada, D., García-Mora, A., Culebro-García, C., Castillejos-Molina, R., Sotomayor,
M., Feria-Bernal, G., & Rodríguez-Covarrubias, F. (2013).Prognostic factors in
emphysematous pyelonephritis.ActasUrológicasEspañolas (English Edition), 37(4), 228-
232. doi.org/10.1016/j.acuroe.2012.03.019

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Triposkiadis, F. K., Butler, J., Karayannis, G., Starling, R. C., Filippatos, G., Wolski,
K., ...&Skoularigis, J. (2014). Efficacy and safety of high dose versus low dose
furosemide with or without dopamine infusion: the Dopamine in Acute Decompensated
Heart Failure II (DAD-HF II) trial. International journal of cardiology, 172(1), 115-121.
doi.org/10.1016/j.ijcard.2013.12.276
Van Hook, J. W. (2014). Acute kidney injury during pregnancy.Clinical obstetrics and
gynecology, 57(4), 851-861.doi: 10.1097/GRF.0000000000000069
Zarbock, A., Gomez, H., &Kellum, J. A. (2014). Sepsis-induced AKI revisited:
pathophysiology, prevention and future therapies. Current opinion in critical care, 20(6),
588.doi: 10.1097/MCC.0000000000000153