Pyelonephritis: Nursing

Pyelonephritis is an ascending urinary tract infection that causes inflammation of the kidneys and the renal pelvis. Alright, let’s quickly review the anatomy and physiology of the urinary tract.

The kidneys are bean-shaped organs located behind the peritoneum on either side of the vertebral column, just below the rib cage.

Now, the kidneys are composed of the renal parenchyma and a collecting system. The renal parenchyma is the solid, functional part of the kidneys, where blood is filtered and urine is produced.

This urine is then drained into the renal pelvis, which then narrows to form the ureter, and transports urine to the bladder.

Ultimately, urine exits the bladder through another structure called the urethra. Now, pyelonephritis is most often caused by bacterial infection; and the most common bacteria are Escherichia coli.

Other potential bacteria include Proteus species, Enterobacter species, Enterococcus species, and Klebsiella species, as well as Pseudomonas aeruginosa.

Less frequently, pyelonephritis is caused by Staphylococcus species, Salmonella species, and fungi like Candida species.

One of the main risk factors for pyelonephritis is urinary stasis or retention. This occurs when the bladder is not able to completely empty, and can be associated with prolonged bed rest or paralysis, or with obstruction of the urinary tract.

Obstruction can be caused by structural abnormalities like strictures; kidney stones or tumors; and scarring from pelvic radiation or surgery, recurrent infections, or traumatic injuries.

Another important risk factor for pyelonephritis is urinary reflux, which refers to the backflow of urine from the bladder to the ureters or kidneys.

This can be caused by structural abnormalities, like narrowing in the bladder neck or urethra, or an abnormal ureter valve that stays open even when the bladder is full, allowing backflow of urine.

Other causes of urinary reflux include bladder stones, bladder tumors, and benign prostate enlargement. In addition, both stasis and reflux can also occur due to reduced bladder tone from diabetic neuropathy, spinal cord injuries, and neurodegenerative diseases like multiple sclerosis.

Finally, additional risk factors for pyelonephritis can include having a lower urinary tract infection, as well as being assigned female at birth, hospitalization, having indwelling urinary catheters, and being immunocompromised.

Most often, the pathology of pyelonephritis develops as an ascending urinary tract infection, meaning bacteria start by colonizing the urethra and bladder, and then make their way up the ureters and kidneys.

Less frequently, the kidneys can get infected via spread through the bloodstream, usually as a consequence of bacteremia.

Once bacteria reach the kidneys, they usually start by adhering to the renal epithelium of the tubules; this ultimately triggers an inflammatory response, and attracts white blood cells that fight off the infection.

Now, pyelonephritis can either be acute or chronic. With acute pyelonephritis, there’s a sudden infection of the kidney that results in inflammation, local edema, and even necrosis.

On the other hand, chronic pyelonephritis usually results from recurrent episodes of acute pyelonephritis, which can eventually lead to fibrosis and scarring of the kidney.

Moving on to the clinical manifestations, clients with acute pyelonephritis usually experience fever, chills, and malaise, along with flank pain or abdominal discomfort, as well as nausea and vomiting.

Urinary symptoms include nocturia, urgency or frequency of urination, and dysuria or burning sensation when urinating; as well as hematuria and cloudy urine.

In addition, some clients may present with signs like tachypnea, tachycardia, and hypotension; while elderly clients may also have confusion, unexplained anorexia, or failure to thrive.

Now, chronic pyelonephritis has a similar presentation, and additionally, clients can often present with hypertension. Now, clients with pyelonephritis may develop complications like renal abscesses, which are pockets of pus and bacteria that can form within the kidney tissue; and some clients may even develop renal failure.

Another complication of pyelonephritis is urosepsis, which occurs when the causative microorganisms manage to spread into the bloodstream and cause bacteremia; if not promptly treated, urosepsis can lead to septic shock and even death.

Diagnosis of pyelonephritis starts with the client’s history and physical assessment, followed by laboratory tests. Blood tests may reveal leukocytosis on CBC, as well as elevated creatinine, BUN, and inflammatory markers like ESR and CRP, and blood cultures can reveal bacteremia in severe cases; while urinalysis usually shows pyuria, hematuria, and proteinuria, and a dipstick test shows the presence of leukocyte esterase and nitrites.

In addition, a urine culture can be done to identify the causative microorganism. Finally, imaging like ultrasound, X-rays, or CT scan can be used in order to evaluate the kidneys, the degree of inflammation and edema, and the presence of renal abscesses; in addition, the urinary tract can be evaluated for the presence of underlying risk factors, such as structural abnormalities, stones, or tumors; lastly, a specific type of X-ray called cystourethrogram can also be used to takes pictures of the bladder and the urethra while the bladder is full and while the client is urinating; this can help determine if the client has urinary reflux.Treatment of pyelonephritis typically includes adequate nutrition and hydration; as well as antipyretic and analgesic medications like acetaminophen to reduce the pain and fever, and antibiotics to treat the infection.

In some cases, surgical interventions can be performed to correct underlying structural abnormalities. Finally, if the affected kidney is too damaged to function, the client may require dialysis, which is a machine that filters blood to remove waste products and excess fluid; while the worst cases may need nephrectomy, where the kidney or part of it is surgically removed.Now, let’s look at the nursing care you’ll provide to a client with pyelonephritis.

Your priority nursing goals are to treat the infection, manage your client’s symptoms, and prevent complications. First, assess your client’s weight and vital signs, especially temperature; as well as fluid intake and output, noting urine characteristics like color and odor.

In addition, be sure to monitor your client’s laboratory test results, including urinalysis and urine culture results. Then, administer the ordered IV fluids, antipyretics, and antibiotics; and be sure to report to the healthcare provider immediately if you notice signs of an acute kidney injury, which includes a urine output of less than 30 mL per hour, hematuria, or unusual weight gain; as well as signs that indicate urosepsis, which includes tachycardia, tachypnea, hypotension, and altered mental status.

Next, ask your client about their pain, including the onset, quality, severity, location, aggravating or relieving factors, and how frequently they experience pain, as well as for the presence of nausea and vomiting.

Then, assist your client into a position of comfort, administer the prescribed analgesics and antiemetics, and offer warm, moist compresses to help relieve your client’s pain.If your client has an indwelling urinary catheter, be sure to take measures to prevent a catheter-associated urinary tract infection, or CAUTI for short; this includes practicing good hand hygiene and aseptic technique when handling the catheter, as well as maintaining a closed system with unobstructed urine flow, securing the catheter to the client to avoid urethral friction, providing meticulous perineal care, and removing the catheter as soon as it is no longer indicated.Alright, moving onto client and family teaching.

First, review your client’s plan of care, and provide information about pyelonephritis and their prescribed medications.

In addition, stress the importance of following up after discharge for a urine culture when they’ve completed their oral antibiotic regimen.

Then, teach your client how to decrease the risk of future urinary tract infections by drinking plenty of fluids; as well as emptying their bladder at least every 2 to 3 hours; and practicing perineal hygiene practices, such as voiding before and after sexual intercouse, and avoiding vaginal douches, harsh soaps, and powders in the perineal area.

Advise your client to notify their healthcare provider if they experience symptoms of a recurrent infection, including fever, urinary frequency and urgency, as well as burning or pain with urination, and flank pain.

Now, if your client has chronic pyelonephritis, stress the importance of blood pressure control to help slow the progression of any kidney dysfunction.

Advise your client to notify their healthcare provider if they notice any symptoms of kidney disease, including weight gain, swelling, blood in the urine, or changes in the amount of urine they are producing.

Lastly, instruct your client to increase their fluid intake, and to contact their healthcare provider if they notice any signs of infection, as well as any changes to their urine color and odor.

Alright, as a quick recap… Pyelonephritis is an ascending urinary tract infection that leads to inflammation in the kidneys and renal pelvis.

While multiple bacteria can cause pyelonephritis, the most common bacteria is Escherichia coli. Risk factors include urinary stasis or retention, urinary reflux, reduced bladder tone, and having a lower urinary tract infection, as well as being assigned female at birth, hospitalization, having indwelling urinary catheters, and being immunocompromised.

Pyelonephritis often develops as an ascending urinary tract infection, meaning bacteria start by colonizing the urethra and bladder, and then make their way up the ureters and kidneys; less frequently, the kidneys can get infected via spread through the bloodstream.

Clinical manifestations include fever, flank pain, abdominal discomfort, nausea, and vomiting; as well as urinary symptoms like nocturia, urgency, frequency, dysuria, hematuria, or cloudy urine; and some clients can develop tachypnea, tachycardia, and hypo- or hypertension.

Potential complications include renal abscesses, renal failure, and urosepsis. Diagnosis involves history and physical assessment, followed by laboratory tests like CBC and inflammatory markers, as well as urinalysis and urine culture, and imaging like ultrasound, X-rays, CT scan, or a cystourethrogram.

Pyelonephritis is treated with adequate nutrition and hydration; as well as medications like antipyretics, analgesics, and antibiotics; surgery to address underlying structural abnormalities,