Acute pyelonephritis • May or may not be febrile

Overview • If present, fever of 102° F (38.9° C) or higher

• Bacterial infection of the renal parenchyma • Shaking chills
• Affecting one or both kidneys • Negative pelvic examination findings
• Good prognosis; extensive permanent damage rare Diagnostic test results
• Also called acute infective tubulointerstitial nephritis Laboratory
Pathophysiology • Urinalysis and culture and sensitivity testing reveal pyuria,
significant
• Infection spreads from the bladder to the ureters to the kidneys, bacteriuria, low specific gravity and osmolality, and slightly alkaline
commonly through vesicoureteral reflux. urine
• Vesicoureteral reflux may result from congenital weakness at the pH, or proteinuria, glycosuria, and ketonuria (less frequent).
junction • White blood cell count, neutrophil count, and erythrocyte
of the ureter and bladder. sedimentation
• Bacteria refluxed to intrarenal tissues may create colonies of rate are increased.
infection Imaging
within 24 to 48 hours.
• Kidney-ureter-bladder radiography reveals calculi, tumors, or
• Female anatomy allows for higher incidence of infection. cysts in the
Causes kidneys or urinary tract.
• Bacterial infection of the kidneys • Excretory urography shows asymmetrical kidneys, possibly
indicating a
• Escherichia coli the most common colonized organism high frequency of infection.
• Microorganisms the same as those that cause lower urinary tract
infection
(UTI) Treatment
Risk factors General
• Renal procedures that involve instrumentation such as cystoscopy • Identification and correction of predisposing factors for infection,
such as
• Hematogenic infection such as septicemia obstruction or calculi
• Sexual activity in women • Short courses of therapy for uncomplicated infections
• Pregnancy • Rest
• Neurogenic bladder Diet
• Obstructive disease • Increased fluid intake
• Renal diseases Medications
• Structural abnormalities • 14-day course of antibiotics (I.V. or oral fluoroquinolone is drug of
• Lower UTI choice)
Incidence • Urinary analgesics such as phenazopyridine (Azo-Standard)
• Acute pyelonephritis is more common in women than in men. • Antipyretics as needed
• Community-acquired cases occur in 15 per 100,000 annually. Nursing considerations
• Hospital-acquired cases occur in 7 per 10,000 annually. Nursing diagnoses
Complications • Acute pain
• Renal calculi • Excess fluid volume
• Renal failure • Fatigue
• Renal abscess • Impaired physical mobility
• Multisystem infection • Impaired urinary elimination
• Septic shock • Ineffective tissue perfusion: Renal
• Chronic pyelonephritis • Risk for infection
Assessment Expected outcomes
History The patient will:
• Pain over one or both kidneys, occasionally suprapubic • report increased comfort
• Urinary urgency and frequency • maintain fluid balance
• Burning during urination • express feelings of energy and decreased fatigue
• Dysuria, nocturia, hematuria • perform activities of daily living within the confines of the
disorder
• Anorexia, vomiting, diarrhea
• maintain urine specific gravity within the designated limits
• Fatigue, malaise, weakness
• identify risk factors that exacerbate decreased tissue perfusion
• Symptoms that develop rapidly over a few hours or a few days and
• Chills, rigors modify lifestyle appropriately
Physical findings • develop no signs or symptoms of infection.
• Mild to moderate suprapubic pain Nursing interventions
• Pain on flank palpation (costovertebral angle tenderness) • Give prescribed drugs.
• Cloudy urine Monitoring
• Ammonia-like or fishy odor to urine • Vital signs
• Intake and output
• Characteristics of urine
• Pattern of urination
• Daily weight
• Renal function studies
Patient teaching
General
Be sure to cover:
• the disorder, diagnosis, and treatment
• avoidance of bacterial contamination by following hygienic
toileting
practices (wiping the perineum from front to back after bowel
movements
for women)
• proper technique for collecting a clean-catch urine specimen
• drug administration, dosage, and possible adverse effects
• routine checkup for patients with a history of UTI
• signs and symptoms of recurrent infection.
Resources
Organizations
American Association of Kidney Patients: www.aakp.org
National Institute of Diabetes & Digestive & Kidney
Diseases:
www.niddk.nih.gov
Selected references
Diseases, 4th ed. Philadelphia: Lippincott Williams &
Wilkins, 2006.
Ramakrishnan, K., and Scheid, D.C. “Diagnosis and
Management of
Acute Pyelonephritis in Adults,” American Family Physician
71(5):933-42, March 2005