Pyelonephritis

N220
Erin Adamic, Kristina Boltz, Van Mai,
Chelsea Poligratis

What is it?

Most urinary tract infections involve only the

bladder and urethra (lower urinary tract
system)
Pyelonephritis results when a UTI progresses
to involve the upper urinary system (kidneys
and ureters)

Pathophysiology

Acute - Active bacterial infection; involves acute tissue inflammation, tubular cell necrosis, and
possible abscess formation
Infection is scattered within the kidney leading to fibrosis and scar tissue to develop from the
inflammation; calices thicken, and scars develop in the interstitial tissue
Chronic - Results from repeated or continued upper UTIs; often occurs with a urinary tract defect,
obstruction, or most commonly, when urine refluxes from the bladder back into the ureters
Reflux within kidney can occur when some papillae in the kidney do not close properly;
inflammation and fibrosis lead to deformity of the renal pelvis and calices
This repeated or continuous infection creates additional scar tissue, changing blood vessel,
glomerular, and tubular structure
As a result, filtration, reabsorption, and secretion are impaired and kidney function is reduced

Etiology and genetic risk

Single episodes of acute pyelonephritis are d/t entry of bacteria, especially during pregnancy,
obstruction, or reflux
Chronic pyelonephritis usually occurs with structural deformities or obstruction with reflux; reflux or
obstruction is often caused by stones or neurogenic impairment of voiding
Reflux more common in children who have acquired scarring during acute infection or have
anatomic anomalies; reflux and scarring contribute to chronic pyelonephritis as an adult, and if
did not have reflux as a child usually d/t spinal cord injury, bladder tumor, prostate enlargement,
or urinary tract stones

 Occurs often in patients who had a urinary

catheter placed, DM (d/t reduced bladder
tone that increases risk) or chronic kidney
stones, or those who overuse analgesics
Patients w/ chronic stone disease stones may retain organisms
resulting in ongoing infection and
kidney scarring
NSAID use can lead to papillary
necrosis and reflux
Most common causing organism is E.coli

Incidence/Prevalence

Approximately 250,000 cases of acute cases each year, resulting in more than 100,000

Clinical manifestations

Acute

Chronic

Fever
Chills
Tachycardia and tachypnea
Flank, back, or loin pain
Tender costovertebral angle (CVA)
Abdominal, often colicky discomfort
N/V
General malaise or fatigue
Burning, urgency, or frequency of urination
Nocturia
Recent cystitis or tx for UTI

Hypertension
Inability to conserve sodium
Decreased urine concentrating ability,
resulting in nocturia
Tendency to develop hyperkalemia and
acidosis

Medical Treatment

Drug Therapy- Antibiotics will be prescribed to treat infection (Most common cause is E.Coli) Broad
Spectrum - Until Urine and blood culture and sensitivity are known and more specific antibodies are
prescribed.
Antibiotics which may be used to treat E. coli infection include amoxicillin, as well as other semisynthetic
penicillins, manycephalosporins, carbapenems, aztreonam, trimethoprim-sulfamethoxazole, ciprofloxacin,
nitrofurantoin and the aminoglycosides.

Medical Treatment

Urinary antiseptic drugs (Such as Nitrofurantoin) is prescribed for comfort. ( effective against upper tract
infection, recurrent bacteriuria, and as a long-term suppressive agent in children and pregnant patients with
only a low incidence of the development of resistance)
Nutrition and fluid therapy is also important to ensure adequate healing can occur and fluid intake of 2
Liters a day is recommended.

Surgical Treatments

Correct structural problems causing reflux or obstruction of urine outflow or can remove source of infection
Surgical Procedures:
Pyelolithotomy (To remove large stones in renal pelvis that blocks urine flow and causes infection)
Ureteral Diversion or Reimplantation of Ureter (to restore proper bladder drainage through another site in
the bladder wall for poor ureteral valve closure or dilated ureters)
Nephrectomy (LAST RESORT removal of kidney)

Nursing Assessment

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Medical Hx
Physical Assessment/Clinical Manifestations
Psychosocial Assessment
Laboratory Assessment
Imaging Assessment
Other Diagnostic Assessment

Medical history

Urinary tract infections (UTIs)

UTIs occurred with pregnancy
Diabetes mellitus, Stone disease, Genitourinary tract defects
Previous episodes of pyelonephritis or similar symptoms
Recent cystitis or treatment for urinary tract infection (UTI)
Diseases or treatments that causes immunosuppression

Physical assessment

1. Ask patient to describe any urinary symptoms or abdominal discomfort

Burning, urgency, or frequency of urination, nocturia
2. Inquire about any history of repeated low-grade fevers
3. Inspect the flanks if pain present
4) Gently palpate the costovertebral angle (CVA)
Enlargement, asymmetry, edema, or redness of CVA indicate inflammation
Tenderness or discomfort may indicate infection or inflammation

Psychosocial assessment

Anxiety/ Fear
Embarrassment
Guilt

Laboratory Assessment

1) Urinalysis: positive leukocyte esterase, presence of white blood cells and bacteria.
2) Nitrite dipstick test: E. coli
3) Urine culture (clean-catch method) determine whether gram-positive or gram-negative organisms
4) Blood cultures
5) C-reactive protein and erythrocyte sedimentation rate to determine the presence of inflammation
6) Examining antibody-coated bacteria in urine

Imaging Assessment

x-ray of the kidneys, ureters, and bladder (KUB) and IV urography are performed to diagnose stones or
obstructions.
cystourethrogram

Goal and Expected Outcomes

Managing pain to achieve an acceptable state of comfort

Education:
1. Ensure the patient's understanding of treatment and preventive measures can be successful.
2. Adequate fluid to prevent stone and infection
3. Appropriated nutrition: decrease protein & calcium
4. Personal hygiene
5. Minimize embarrassment patient will not hesitate to seek help when needed.