0800: A 9-year-old female is admitted with lethargy and fever. The client has a history of spina bifida, myelomeningocele, L2 level diagnosed at birth. History of recurrent UTIs, daily in-and-out catheterization at home, and chronic constipation. Home meds include oxybutynin 5 mg bid, polyethylene glycol 3350 daily, and acetaminophen PRN.

0815: Assessment complete. The child wakes up easily, reports pain 4/10, and points to the left, lower flank area when asked to point to the site of pain. A phlebotomist is at the bedside to collect blood specimens for laboratory orders.

0830: In and out (straight) urinary catheterization completed to collect urine specimens. 30 mL of urine was noted when catheterized.

0820

• In & out catheterization
• Urinalysis (UA) with reflex to culture & sensitivity
• Complete Blood Count (CBC) with differential
• Blood cultures (BC) x 2 sets
• Computed tomography (CT) scan with contrast of abdomen and pelvis

0815: Assessment complete. The child wakes up easily, reports pain 4/10, and points to the left, lower flank area when asked to point to the site of pain. A phlebotomist is at the bedside to collect blood specimens for laboratory orders.

0830: In and out (straight) urinary catheterization completed to collect urine specimens. 30 mL of urine was noted when catheterized.

1100: Child crying and restless in bed. When asked to rate pain, the child rates pain 10/10 and points to the lower left flank area and indicates it extends to the left lower abdomen. The provider at the bedside confirms a diagnosis of pyelonephritis.

1000

CT Abdomen and Pelvis Report with Contrast

Results:

• Left kidney is enlarged with areas of decreased perfusion (wedge-shaped hypodense cortical regions), consistent with focal areas of inflammation.
• No renal calculi or hydronephrosis observed.
• Right kidney is normal in size and enhancement.
• Bladder is distended, with mild wall thickening—no intraluminal mass or calculi.
• No evidence of abscess, obstruction, or free fluid.

1045

Urine Culture Preliminary Results:

Heavy growth of lactose-fermenting gram-negative rods

Blood Culture Preliminary Results:

No growth

1100

• Insert peripheral IV
• Infuse D5W ½ NS at 20 mL/hr
• Strict intake and output
• Acetaminophen 10 mg/kg by mouth q6 PRN pain or temperature greater than 101.0 oF (38.3 oC)
• Oxybutynin 5 mg orally q8h
• Cefotaxime 50 mg/kg every 6 hours IV infusion
• Clean Intermittent Catheterization (CIC) q4-6 hours