PYELONEPHRITIS
I. INTRODUCTION
Pyelonephritis is a kidney infection usually caused by bacteria that have traveled to the
kidney from an infection in the bladder. It is most often occurs as a result of urinary tract
infection, particularly in the presence of occasional or persistent backflow of urine from the
bladder into the ureters or kidney pelvis (vesicoureteric reflux).
There are two types of Pyelonephritis: Acute uncomplicated pyelonephritis and chronic
pyelonephritis. They differ primarily in their clinical picture and long-term effects. Acute
uncomplicated pyelonephritis is a sudden development of kidney inflammation while chronic
pyelonephritis is a long-standing infection that does not clear.
Diagnosing and managing acute pyelonephritis is not always straightforward. In the age
range of 5-65 years, it typically presents in the context of a symptomatic (eg, dysuria, frequency,
urgency, gross hematuria, suprapubic pain) urinary tract infection (UTI) with classic upper
urinary tract symptoms (eg, flank pain, back pain) with or without systemic symptoms (eg, fever,
chills, abdominal pain, nausea, vomiting) and signs (eg, fever, costovertebral angle tenderness)
with or without leukocytosis. However, it can present with nonspecific symptoms.
In contrast to the plethora of data available for the treatment of lower UTI, less
substantial data are available regarding the appropriate antibiotic choice or duration of therapy
for acute pyelonephritis, but useful recommendations can be made. An additional cause for
concern is the growing antimicrobial resistance to accepted standards of treatment. The current
emphasis on cost effectiveness and the advent of newer antibiotics have led clinicians to
reevaluate the benefit of hospitalization to treat patients with acute pyelonephritis; however, if
the patient is managed as an outpatient, he or she should have close follow-up care. The first
follow-up visit should occur in 1-2 days, depending on the clinician's estimation of the severity
of the infection. Any deterioration or unsatisfactory improvement warrants admission for
intravenous antibiotics and evaluation for any complications. Most cases of uncomplicated
pyelonephritis in young women can be managed successfully on an outpatient basis.
The estimated annual incidence of pyelonephritis was 27.6 cases per 10,000 persons.
Only 7% of cases required hospitalization. Escherichia coli caused 85% of cases, including 6 of
7 cases among inpatients for whom data were available. Of E. coli isolates, 85% were sensitive
to trimethoprim-sulfamethoxazole, while 99% were susceptible to ciprofloxacin.
Local and Foreign trends
Our local trend is a health program/service made by the Department of Health which is
about “Renal Disease Control Program (REDCOP)”
The REDCOP consists of the following components: RDR (Renal Disease Registry);
Study on GN and Kidney Stones; Follow-up of PNP cases; and Organ Donation.
This is a relatively new program with the objective of reducing the mortality and
morbidity rates caused by renal diseases. (http://www.doh.gov.ph/CHD-12-
new/degenerative.htm)
Scientists led by a University of Cincinnati (UC) kidney expert have found that a
naturally occurring protein that normally fights cancer cells can also cause severe kidney failure
when normal blood flow is disrupted. This finding, seen in mice in which the gene controlling
the protein is actually expressed or "turned on," could provide a target for drugs that will reduce
the risk of kidney damage in humans, the researchers believe.
Acute kidney failure is a life-threatening illness caused by sudden, severe loss of blood
flow to the kidneys (ischemia). Despite advances in supportive care, such as dialysis, severe
kidney injury is a major cause of death.
The protein, thrombospondin (TSP-1), is known for its role in fighting cancer. It does this
by killing off cancer cells and preventing the tumor from building a greater blood supply.
Although TSP-1 causes irreversible, severe kidney damage when blood flow to mouse
kidneys is disrupted, the researchers say, this only occurs in animals whose TSP-1 gene is turned
on.
The study showed that the protein damages kidney cells when blood flow is reduced for
30 minutes or more. When blood flow is restored to the kidneys, if TSP-1 protein is present,
normal kidney function doesn't return.
"This raises the important possibility that TSP-1 may serve as a target in preventing or
successfully treating acute kidney failure," said Dr. Soleimani. "Understanding the mechanisms
of kidney cell injury moves us that much closer to preventing this life-altering damage from
happening.
"If we can develop a drug that will inhibit or turn off the TSP-1 gene function, then severe
kidney damage could be prevented--even during a 30-minute disruption in blood flow," he said.
"Since the incidence of death remains high in patients with damaged kidneys, prevention
or early treatment of acute kidney failure will increase survival."
The study showed that the damaging protein is released rapidly, in response to
diminished blood flow, in mice that have the active TSP-1 gene. TSP-1 also killed kidney cells
when exposed to them in a Petri dish.
"Most importantly," Dr. Soleimani said, "we found that genetically engineered mice,
which lack TSP-1 protein, were significantly protected from kidney damage. Mice without TSP-
1 preserved their kidney function relatively well, even after being subjected to a 30-minute
disruption of blood flow to the kidneys.
"Consequently, this study raises an important possibility that TSP-1 may serve as a target
for preventing or successfully treating acute kidney failure," Dr. Soleimani said. (Source:
http//:www.sciencedaily.com)
This study was a part of the partial requirement in NCM 104 (R.L.E.) of the Fourth year
college students of the Dee Hwa Liong College Foundation. This study regarding Acute
Pyelonephritis may serve as a reference for each student that will encounter this case soon in
their future career as professional nurses. It may also help in developing and widening the
knowledge of each health care provider to be more skillful and competent in rendering care
among their client with same cases.
B. Objectives
After the completion of the study, the nurse – researcher will be able to;
Gather the personal information of the client, from his / her past medical history and from
the family’s health history
Determine the dependent and independent function as a nurse in rendering health care
services.
Patient – Centered Objectives
Acquire and enhance knowledge about the disease, the factors that contribute to the
development of the client’s condition
Build trust and gain respect among the nurses and able to deepen information about his /
her condition
Meet the needs of the client in the best way possible, either physically, mentally, socially,
spiritually and emotionally
A. Personal Data
Ms. Pye, 18 years old, a Filipino was born at year 1992 and the eldest among the three
children of Mr. and Mrs. Kidney. A roman catholic and an out-of-school youth
.
B. History of past illness
Ms. Pye only experienced common cough and colds, fever and never been hospitalized. Her
family believes on herbal medicines. Instead of going straight to the hospital for check-ups, they
try to cure it using herbal medicines and if not successful, that’s the time they will seek medical
advice. In the case of Ms. Pye, her godmother gave her powdered charcoal mixed in water to
cure the disease.
Ms. Pye and her family also believed in superstitions, “pagtatawas” and “albularyo”
According to Ms. Pye she likes to eat junk foods while watching television and do not drink
enough water. She just stays inside the house the whole day doing the household choirs.
Prior to admission, Ms. Pye experienced fever, vomiting and generalized body weakness for
one week. Ms. Pye self medicated and took Biogesic and Alaxan. She also took powdered
charcoal mixed in a glass of water as advised by her godmother.
She was rushed by her mother to Ospital Ning Angeles on June 16, 2010 at 9:10pm with
chief complaint of fever and vomiting.
D. Physical examination
Vital signs:
Temp: 38.1 ºC
PR: 89 bpm
RR: 22 bpm
BP: 120/90 mmHg
Appearance: weak and pale
Eyes: slightly pale conjunctiva
Lungs: clear breath sounds, (-) rales, (-) wheeze
Heart: (-) murmurs
Abdomen: soft tender abdomen, (-) bowel sounds
Extremities: strong pulses, (-) cyanosis
Urinary System produces and excretes urine from the body. Urine is a transparent yellow
fluid containing unwanted wastes, mostly excess water, salts, and nitrogen compounds. The
major organs of the urinary system are the kidneys, a pair of bean-shaped organs that
continuously filter substances from the blood and produce urine. Urine flows from the
kidneys through two long, thin tubes called ureters. With the aid of gravity and wavelike
contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal
adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the
tubelike urethra.
An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at
a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products.
Excessive or inadequate production of urine may indicate illness and doctors often use
urinalysis (examination of a patient’s urine) as part of diagnosing disease. For instance, the
presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus; bacteria in the
urine signal an infection of the urinary system; and red blood cells in the urine may indicate
cancer of the urinary tract.
The kidneys lie embedded in fat tissue on either side of the backbone at about waist
level. Each fist-sized kidney is reddish-brown, weighs 140 to 160 g (5 to 6 oz), and is
similar in shape to the kidney beans sold at the supermarket.
On the inner border of each kidney is a depression called the hilum, where the renal
artery, the renal vein, and the ureter connect with the kidney (the adjective renal is from
the Latin term renalis, meaning of or near the kidneys). The renal artery delivers over
1700 liters (450 gal) of blood to the kidneys each day, which these organs filter and
return to the heart via the renal vein. Each kidney contains about 1 million microscopic
coiled channels, called nephrons, which perform this critical blood-filtering function and
produce urine in the process.
These waste materials then pass from the nephrons into a funnel-shaped area called
the renal pelvis. From the renal pelvis, waste trickles out of the kidney into the ureter,
which is about 25 to 30 cm (10 to 12 in) long and about 0.5 cm (0.2 in) in diameter. The
ureter empties into a hollow, muscular sac called the urinary bladder. A valvelike flap of
tissue at the point of entry into the bladder prevents urine from flowing backward into the
ureter. The urinary bladder is able to expand and contract according to how much urine it
contains. As it fills with urine, the walls of the bladder stretch and become thinner, with
the bladder itself lengthening to 12.5 cm (5 in) or more and holding up to about 0.5 liter
(1 pt) of urine. A ringlike sphincter muscle surrounds the bladder’s outlet and prevents
spontaneous emptying.
IV. PATHOPHYSIOLOGY
Systematic arteries
urethra
Kidney
Infection Inflammation of renal tissue fever pain
Increase WBC and platelet small abscess in the calyx surface pain,
bladder
irritation
fever
Bacterial invasion
urethra
Kidney
Infection
Hematology
Hemoglobin
A hemoglobin 116 g/dL M 140-180 g/dL Result was below
determination is F 120-160 g/dL normal, means
used to evaluate the that low transport
hemoglobin content and exchange of
(and thus the iron oxygen to the
status and oxygen- tissues and
carrying capacity) carbon dioxide
of erythrocytes by from the tissues.
measuring the
number of grams of
hemoglobin per
deciliter of blood.
Determine if there
Lymphocytes is enough cell that .26 % 0.10 - 0.48 % The result is
produces antibodies within the normal
and other chemicals range which
responsible for indicates normal
destroying immune
microorganisms; response.
contributes to
allergic reactions,
graft rejection,
tumor control, and
regulation of the
immune system
Urinalysis is part of Color:
URINALYSIS routine diagnostic Yellow Yellow, Clear -Urine ranges from pale yellow to
and screening amber because of the pigment
evaluations. It can urochrome (production of bilirubin
reveal a significant metabolism)
amount of
preliminary
information about
the kidneys and Transparency:
other metabolic
processes. Cloudy Clear
Urinalysis includes -Cloudy urine may contain RBC’s
remarks as to the or WBC’s bacteria, fat, or chyle, if
color, appearance may reflect renal infection.
and odor, pH, and Albumin:
presence of proteins,
glucose, ketones,
Trace Trace
and blood and -Proteinuria may result from renal
leukocyte failure of disease
esterase. In addition,
the urine is Acidic-increased formation of
examined pH: acids in the urine
microscopically for
RBC’s WBC’s, Acidic Alkaline Fixed specific gravity in which
casts, crystals and
values remain 1.010 regardless of
bacteria this
fluid intake occurs in chronic
procedure was done
glumerolonephritis with several
to our pt. to check
Specific gravity: renal damage.
test if there is any
complication/ingesti
on on her kidney or 1.0200 - Indicates presence of infection
if her kidney’s
functioning well. 1.001-1.035
Pus cells:
Ultrasound It is a non- invasive test Sonically normal kidneys Sonographic examination Sonically normal
performed which and urinary bladder. reveals bilaterally normal kidneys and
provides images of the size kidneys with smooth urinary bladder.
renal and urinary cortical outlines.
bladder. Echogencity is within
normal. No evident renal
or suprarenal mass lesion
noted.
No lithiasis or
hydronephrosis seen.
Perirenal area are
unremarkable.
a. Doctor’s Order
6 – 16 – 10
6 – 17 – 10
continue meds
repeat UA
FTF: D5LRS 1L x 8º
schedule for KUB ultrasound
Treatment:
Intravenous fluids
Medical General Description Indication Client’s initial Client’s response to
management / reaction to noted the treatment
Treatment
D5 LRS 1L It is a hypertonic solution To replace fluid loss and Patient has no Patient tolerated IV
that has an osmolarity electrolyte loss, maintain complain regarding his infusion. He does not
higher than serum patient’s hydration, IV infusion. complain of any pain or
osmolarity when a patient nutritional status and fluid irritation.
relieves a hypertonic IV balance. It is use to supply
solution; serum osmolarity the necessary nutrient to
initially increases causing the patient.
fluid to be pulled from the
intestine and intracellular
compartments into the
blood vessels.
D. Diet
DAT – the patient can take anything by mouth as long as she can tolerate it to nourish the
body with nutrients.
C. Drug study
Therapeutics:
Analgesia,
Antipyresis.
Problem #1: Acute pain related to frequency of urination
M – edication
Patient was advise to continue home medication (noting on medication that should not be able to
discontinue abruptly) to maintain a normal functioning of the body and maintain homeostasis. The treatment
regimen ordered by the doctors must be followed strictly and should not be stopped to prevent the aggravation
of the condition. The full course of antibiotics should be followed. (At least 7 days.)
E - xercise
Discuss to the client importance or help client develop a program of exercise and relaxation techniques
as tolerated.
T – eachings
Moreover, a teaching plan that affect client’s holistic wellness should be done in order to maintain an
environment that is conducive for health promotion.
H – ygiene
OPD schedule
Proper referral is best for the health care provider to evaluate condition of the client, whether it is
improving or not. Also for early detection of other underlying conditions.
Patient was instructed to go back after 1 week at Ospital Ning Angeles OPD department.
D – iet
Instructed to have proper diet especially foods rich in vitamin C, and increase fluid intake.