Acute pyelonephritis

Treatment-Activity

Rest during the initial period; gradually increase activity as infection resolves. No return to work for approximately 2 weeks.

Nursing Considerations-Associated Nursing Procedures

12- or 24-hour timed urine collection Blood pressure assessment Calculating and setting an IV drip rate Fall prevention Health history interview and physical assessment IV bag preparation IV bolus injection IV catheter insertion IV pump use IV secondary line drug infusion IV solution change IV time tape use IV tubing change Indwelling urinary catheter (Foley) care and management Indwelling urinary catheter (Foley) irrigation Intake and output assessment Intermittent infusion device drug administration Nutritional screening Oral drug administration Pain management Pulse assessment Pulse oximetry Straining urine for calculi Temperature assessment Urine glucose and ketone tests Urine pH Urine specific gravity Urine specimen collection from an indwelling urinary catheter (Foley) Urine specimen collection, random Venipuncture Weight measurement

Treatment-Medications

7- to 14-day course of I.V. or oral antibiotics, such as ciprofloxacin (Cipro), levofloxacin (Levaquin), ceftriaxone sodium (Rocephin), gentamicin sulfate (Garamycin), ampicillin, amoxicillin (Amoxil), vancomycin hydrochloride (Vancocin), cephalexin (Keflex), trimethoprim-sulfamethoxazole (TMP-SMX), ampicillin sodium-sulbactam sodium (Unasyn), aztreonam (Azactam), meropenem (Merrem I.V.), piperacillin sodium-tazobactam sodium (Zosyn), ticarcillin disodium -clavulanate sodium (Timentin), cefpodoxime proxetil (Vantin), and amoxicillin-clavulanate potassium (Augmentin) Urinary analgesics such as phenazopyridine hydrochloride (Azo-Standard) Antipyretics, such as acetaminophen or ibuprofen , as needed

Nursing Considerations-Nursing Diagnoses

Acute pain Excess fluid volume Fatigue Impaired physical mobility Impaired urinary elimination Risk for ineffective renal perfusion Risk for infection

Overview-Incidence

Acute pyelonephritis is more common in women than in men. It affects all ages but increases after age 50. Pyelonephritis is very common, with 12 to13 cases occurring annually per 10,000 in women and 3 to 4 cases per 10,000 in men. Overall incidence is 250,000 cases diagnosed annually with approximately 192,000 cases requiring admission to the hospital. Acute pyelonephritis occurs in approximately 20% to 30% of all pregnancies with women who experience asymptomatic bacteriuria.

Overview-Causes

Bacterial infection of the kidneys Escherichia colli the most common colonizing organism Other gram-negative causative organisms, including Proteus, Klebsiella, Serratia, Clostridium, Pseudomonas, and Enterobacter Other causative organisms, such as Enterococcus, Staphylococcus, and Candida

Overview

Bacterial infection of the renal parenchyma Affecting one or both kidneys Wide-ranging presentation, from mild to septic shock Good prognosis, rarely with extensive permanent damage Also called acute infective tubulointerstitial nephritis

Treatment-Surgery

Drainage of abscess or removal of obstructing calculus, if indicated

Overview-Risk Factors

Female anatomy allows for higher incidence of infection. Renal procedures that involve instrumentation, such as cystoscopy Hematogenic infection, such as septicemia Sexual activity in women (frequency of more than 3 times per week within the past 30 days) Spermicide use Pregnancy Neurogenic bladder Structural urinary tract abnormalities Lower urinary tract infection (UTI) Indwelling urinary catheter Nephrolithiasis Prostatic enlargement Stress incontinence Diabetes Previous history of acute pyelonephritis (within the past year)

Nursing Considerations-Nursing Interventions

Give prescribed drugs, such as antibiotics, urinary analgesics, and analgesics. Ensure patent access if I.V. antibiotic therapy is ordered. Inspect urine for color, clarity, and odor. Provide comfort measures to minimize pain. Implement measures to reduce body temperature as appropriate, such as wearing lightweight, loose clothing; use cooling blankets as necessary to reduce significantly elevated body temperature. Encourage bed rest and activity limitations during initial therapy; assist with gradual resumption of activity as condition improves. Implement energy conservation measures; cluster nursing activities to promote rest. Encourage the patient to increase fluid intake. Administer oral and/or I.V. fluids as ordered. Urge good perineal hygiene practices; encourage frequent and complete voiding. Obtain specimens for laboratory testing, including repeat urine cultures, complete blood counts, and blood cultures as indicated.

Treatment-General

Identification and correction of predisposing factors for infection, such as obstruction or calculi Short courses of therapy for uncomplicated infections Rest

Treatment-Diet

Increased fluid intake

Overview-Pathophysiology

Infection spreads from the bladder to the ureters to the kidneys, commonly through vesicoureteral reflux. Vesicoureteral reflux may result from congenital weakness at the junction of the ureter and bladder. Bacteria refluxed to intrarenal tissues may create colonies of infection within 24 to 48 hours. Bacteria attach to the epithelium leading to an inflammatory response; chemokines are released and attach to neutrophil activating chemokine receptors, which alter the epithelial barrier and allow polymorphonuclear leukocytes to cross into the urine. Bacteria invade the renal parenchyma. Female anatomy allows for higher incidence of infection.

Diagnostic Test Results-Imaging

Kidney-ureter-bladder radiography reveals calculi, tumors, or cysts in the kidneys or urinary tract. Excretory urography shows asymmetrical kidneys, possibly indicating a high frequency of infection. Computed tomography identifies changes in renal parenchymal perfusion, evidence of perinephric fluid. Renal ultrasonography may reveal infection.

Assessment-Physical Findings

Pain on flank palpation (costovertebral angle tenderness); suprapubic tenderness Cloudy urine; gross hematuria Ammonia-like or fishy odor to urine If present, fever of 100° F (37. 8° C) or higher (may be absent in the elderly) Shaking chills Irritability, sepsis, GI symptoms, inadequate weight gain or loss, and jaundice or gray skin color (infants and children) Negative pelvic examination findings in females (to rule out pelvic inflammatory disease)

Assessment-History

Pain over one or both kidneys, occasionally suprapubic Urinary urgency and frequency Burning during urination Dysuria, nocturia, hematuria Anorexia, vomiting, diarrhea Fatigue, malaise, weakness Symptoms that develop rapidly over a few hours or a few days Chills, rigors

Overview-Complications

Renal calculi Renal failure Renal abscess Renal papillary necrosis Multisystem infection Septic shock Chronic pyelonephritis or renal damage Emphysematous pyelitis or cystitis

Diagnostic Test Results-Laboratory

Urinalysis and culture and sensitivity testing reveal pyuria, significant bacteriuria, low specific gravity and osmolality, and slightly alkaline urine pH or proteinuria, glycosuria, and ketonuria (less common). White blood cell count, neutrophil count, and erythrocyte sedimentation rate are increased.

Nursing Considerations-Monitoring

Vital signs Intake and output Characteristics of urine Pattern of urination Daily weight Results of urine cultures and renal function studies

Patient Teaching-General

disorder, diagnosis, and treatment, including the fact that most patients respond to treatment in approximately 48 hours temperature monitoring, with notification of the practitioner if temperature is higher than 100° F (37.8° C) prescribed drug therapy, including drug names, dosages, schedule for administration and duration of therapy, and possible adverse effects possible changes in the color of urine; for example, phenazopyridine will turn urine orange and stain clothing that comes into contact with urine possible signs and symptoms of hypersensitivity reactions to prescribed drugs and the need to notify the practitioner need to complete the full course of therapy, even if feeling better appropriate hygienic toileting practices, including wiping the perineum from front to back after bowel movements for women need for rest and minimal activity, including not returning to work for 2 weeks signs and symptoms of recurrent infection proper technique for collecting a clean-catch urine specimen routine follow-up examination and urine cultures, if indicated, especially if the patient has a history of UTIs.

Nursing Considerations-Expected Outcomes

report increased comfort maintain fluid balance express feelings of energy and decreased fatigue perform activities of daily living within the confines of the disorder maintain urine specific gravity within the designated limits identify risk factors that exacerbate decreased tissue perfusion and modify lifestyle appropriately develop no signs or symptoms of infection.