A Case of Acute Pyelonephritis

Adult Phase I
Daryl C. Diez

Introduction:
Acute pyelonephritis is a form of urinary tract infection that causes sudden
and severe infection and inflammation of the kidney tissue, calyces, and renal
pelvis. It is commonly caused by bacterial infection that has spread up the
urinary tract or travelled through the bloodstream to the kidneys, frequently
caused by poor personal hygiene and poor aseptic technique like insertion of a
catheter or cystoscope.
The most common pathogens that cause acute pyelonephritis are enteric
bacteria such as Escherichia coli. Gram negative pathogens like Proteus,
Klebsiella, and Pseudomonas. On the other hand, gram positive bacteria like
Enterococcus and Staphylococcus aureus also cause acute pyelonephritis but are
less common.
One of the causes of acute Pyelonephritis is from vesicoureteral reflux
(incompetence of ureterovesical valve, which allows urine to regurgitate into
ureters, usually during voiding time). Renal obstruction (tumors, strictures,
urinary stones), which causes urinary stasis and increases susceptibility of
patients to infection, and trauma are some of the other factors that result in
pyelonephritis. There are also other conditions that predispose a patient more to
pyelonephritis than others. Patients with diabetes, hypertension, chronic renal
calculi, chronic cystitis, and congenital or abnormal urinary tract and pregnant
women are more likely to acquire pyelonephritis than other groups. Although
pyelonephritis is more common in women than in men, men are still susceptible
especially if they have renal obstruction.
Brief discussion:
Statistics:
According to the Philippine practice guideline on the diagnosis and
management of urinary tract infections, UTIs are among the most common
infections encountered by physicians. It is also one of the top 5 reasons for
consultations in health care facilities. 5-7% of consultations in hospitals in

Manila, Cavite and Davao are all due to UTIs. The Philippine Renal Disease
Registry of the Philippine Society of Nephrology reports chronic pyelonephritis as
the cause of end stage renal disease in 11% of patients undergoing maintenance
dialysis and 8% of kidney transplant patients from six centers. UTIs also
constitute over 40% of hospital-acquired infections.

Impact of the disease:

The patient with acute pyelonephritis experiences symptoms such as
fever, flank pain, nausea, vomiting, anorexia, costovertebral angle tenderness
(unilateral / bilateral), and may also experience urgency, frequency and dysuria.
These signs and symptoms affect a patients daily activities, lifestyle and
functioning. Patients often seek medical help because of the alterations in
functioning caused by these signs and symptoms. According to the 2011
Philippine health and welfare yearbook, there were 82,867 and 219, 270 deaths
in the Philippines due to urinary tract infections in the years 2009 and 2010
respectively. This has shown that the number of deaths due to UTIs has
increased. Timely diagnosis and management of the disease is important
because it has significant impact on patient outcomes. The disease requires
prompt medical attention. If not treated properly, a kidney infection can
permanently damage the patients kidneys leading to a more serious renal
problem or the bacteria can spread to the bloodstream and cause a lifethreatening infection.

Role of the nurse:

The role of the nurse when providing care for patients with acute
pyelonephritis is to administer prescribed medications like antibiotics and pain
relievers and by making sure that the patient religiously complies with the
regimen to prevent exacerbation causing the development of renal abscesses,
perinephric

abscesses,

emphysematous,

pyelonephritis,

pyelonephritis resulting to irreversible damage to the kidneys.

and

chronic

Moreover, health teaching regarding prevention of reoccurrence of

infection must be thoroughly reiterated.
History and Assessment:
Patient X, female, 33 years old, was admitted last January 20, 2016 with
complaints of 2 days intermittent fever, pain at the lower part of her abdomen
(hypogastric area) and pain at her right side radiating to the back. The pain
started roughly 4 days prior to admission. Prompted consult due to chills that
she experienced the night prior check-up.
The patient has had no previous hospitalizations. she also does not have
any history of diabetes mellitus, hypertension, and heart diseases or any other
non-communicable, lifestyle related diseases. she doesnt have any known drug
or food allergy.
Upon assessment on 25th of January 2016, data was gathered and
revealed the following: vital signs were: HR 104 bpm, temperature: 38.6
degrees Celsius, respiratory rate of 23 cpm and BP of 130/ 70.
Focused assessment:
Abdomen and urinary system:
Pain on the right lower quadrant of her abdomen radiating to the flank area
(Costovertebral angle tenderness). Pain reported as 8/10
verbalization by the patient that she has difficulty starting a urine stream
and feels pain when voiding
When asked about her intake of fluids, the patient said that he drinks alcohol
occasionally (2-3 bottles) and that he usually drinks coffee (1 cup per day).
He also usually drinks water, juice and energy drinks. He eats home-cooked
meals vegetables, fish and sometimes pork or chicken. He regularly has
junk food or chips as snacks if not he has biscuits. He exercises sometimes
but the most common form of exercise he does is walking. He has a regular
sleeping schedule and does not have any trouble sleeping or staying asleep.
He sleeps for around 5-7 hours per day.

Diagnostic and Laboratory Procedures:

 CBC
Urinalysis
Urine culture and sensitivity

Complete Blood Count

Test

Result

Reference

WBC

17.3 x 10 ^9/L

LYMPH#

2.7 x 10 ^ 9/L

0.8 4.0

MID#

1.4 X 10^9/L

0.1 11.6

GRAN#

13.2 X 10^9/L

2.0 7.0

LYMPH%

15.9%

20 - 40

MID%

8.3%

3.0 10

GRAN%

75.9%

50 - 70

HGB

149 g/L

120 - 160

RBC

4.24 X 10 ^12/L

4.0 5.5

HCT

43.1%

40.0 54.0

MCV

101.8

80.0 100.0

MCH

35.1

27.0 34.0

MCHC

345

320 - 360

RDW-CV

12.6

11.0 16.0

RDW-SD

58.4

PLT

230

150 450

MPV

7.5

6.5 12.0

5.0 10

35.0 56.0

Urinalysis Report
Color

Yellow

Specific gravity

1.035

Pus cells

numerous

Epithelial cells

rare

Mucus Threads

Moderate/ hpf

Transparency

cloudy

ph

6.0

Sugar

negative

RBC cells

0-2

Bacteria

Many/ hpf

Casts

5 LPF

Urine Culture and Sensitivity with mic Report

Escherichia coli- greater than 100,000 organisms per ml

NURSING CARE PLAN

NURSING DIAGNOSIS: Alteration in comfort: Acute pain related to
inflammation of the kidneys secondary to bacterial infection
EXPECTED OUTCOME: The patient will report that there is no pain or that
the pain is controlled. The patient does not exhibit signs of being in pain
(facial grimace, uncomfortable etc.)
Nursing Interventions
INDEPENDENT:

Rationale
1. Helps

evaluate

degree

of

Assess

pain,

noting

characteristic

location,

and

intensity.

discomfort

and

may

reveal

developing complications.

Monitor urine flow and intake and

2. to locally relieve flank pain and to

output.
Use comfort measures, such as
positioning,

back

breathing,

and

activities

such

rub,

deep

diversional
as

reading

promote

relaxation

and

divert

patients attention from the pain

3. to promote feeling of well- being

magazines etc.
to locally relieve flank pain and to
promote

relaxation

and

divert

patients attention from the pain

control

the

infection

and

therefore control the inflammatory

process causing the pain

DEPENDENT
1. Administer

antibiotics

as

analgesics,

and

prescribed
2.Administer
monitor

1. to

their

effectiveness

2. to provide pain relief through

pharmacologic measures

and

the patients response to paincontrol measures.

Evaluation: The patient reported relief of pain and felt relaxed with no
evidence of acute pain.

Nursing

General

Diagnosis

Objectives

Hypertherm

Interventions

The underlying INDEPENDENT:

ia related to infection will be Use measures to decrease body temperature

stimulation
of

treated

and

if indicated: cooling blanket, application of ice

the

to armpits and groins, and so forth.

the therefore

bodys

subsequent

immune

increase in the non-pharmacologic measures

patients
Establish cool environment by opening air
temperature is
vents and window panes
controlled.
Rationale: to promote heat loss by convection

response
secondary
to infection

Rationale: to reduce body temperature using

Encourage client to have adequate fluid

intake

Patients

temperature is Rationale: to prevent dehydration

within

normal

range.

Report fever that persists beyond 72 hours

after

initiating

testing

for

antibiotic

therapy;

complicating

factors

further
will

be

ordered.
Rationale:

to

monitor

for

possible

complications and to provide prompt necessary

treatment to prevent further complications
DEPENDENT:
Administer antibiotics, as prescribed, and
monitor for effectiveness and adverse effects.
Rationale: to treat the underlying infection
Administer

antipyretic

medications

as

prescribed and according to temperature.

Rationale: to lower the patients temperature
to within normal range
Evaluation: The patients temperature is within normal limits.
Nursing

General

Diagnosis

Objectives

Interventions

Impaired

The client will INDEPENDENT:

urinary

regain

eliminatio

urinary patern

normal

Encourage drinking cranberry juice in the

morning and evening

related

to urinary

Rationale: cranberry juice assists to acidify

tract

the urine

infection

Encourage

fluid

intake

to

3000

ml/day,

especially water
Rationale: adequate fluid intake promotes
hydration and assists the kidneys propere
functioning
Monitor intake and output
Rationale: accurate measurements of intake
and output monitor the patients hydration
status

Evaluation: The patients temperature is within normal limits.

Discharge plan:
The nurse should provide appropriate ghalth care teaching regarding the
prevention of recurrence of infection does not happen because chronic
pyelonephritis might occur and chronic pyelonephritis is one of the main causes
of end stage renal disease in the Philippines. The health teachings are the
following and are not limited to:
Proper personal hygiene measures can prevent future infetions.
Teach or reinforce the hygiene measure of cleansing the perineum
from front to back.
Instruct the patient to refrain from using perfumed perineal
products such as tampons and douches, and avoid bubble baths

and hot tubs because they can be irritating to the tissues of the
genitals. Use of such can cause irritation and promote an
environment of bacterial growth.
drinking liberal amount of fluid to flush out bacteri

avoiding urinary irritants (coffee, tea, cola, and alcohol), and

healthy voiding habits (void every 2-3 hours during the day

empty bladder completely to avoid overdistention and stasis).

Information on the medication to be taken at home should also be

given and the patient should be advised to take the medication as
prescribed. The patient should also be reminded to consult the
health care provider for follow- up check, recurrence of symptoms,
and infections that are not responsive to treatment.