OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Introduction
Acute Pyelonephritis is the infection within the renal pelvis, usually
accompanied by infection within the renal parenchyma. The source of sepsis is often
ascending infection from the bladder but haematogenous spread can also occur. It is
usually caused by E.coli, other causative organisms are Klebsiella Pneumoniae, P.
Mirabilis, Streptococcus Fecalis, P. Aeruginosa and Staphylococcus Aureus. If
treatment is unsuccessful and repeated attacks occur, it can lead to Chronic
Pyelonephritis.
The classic presentation in patients with acute pyelonephritis includes fever,
chills, flank pain and urinary frequency with burning sensation.
It can happen at any age, but are much more common in women. In fact,
women are six times more likely to get a kidney infection than men. This is because
a woman's urethra is shorter, making it easier for bacteria to reach the kidneys.
Younger women are most at risk because they tend to be more sexually
active, and having frequent sex increases the chances of getting a kidney infection.
Younger children are also vulnerable to developing kidney infections because they
may be born with an abnormality of the urinary tract or have a condition called
vesico-ureteric reflux, where there is a backflow of urine from the bladder up to the
kidneys. Elderlies are also most likely to develop Pyelonephritis due to poor personal
hygiene and catheterization.
About 1 out of 7,000 people develop pyelonephritis in the Philippines each
year and about 192,000 of them are admitted in the hospital mostly due to
moderate to severe flank pain.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Significance of the Study

Knowing the clinical manifestations, nursing responsibilities, management
and interventions for patients who have this complication will lead to a formation of
comprehensive and effective medical history.

Scope and Limitation

The contents of this study are based on client's past and present data.
Results may vary from one client to another depending on how the client's body
react with a certain procedure or treatment given. Also, the discussion here is
limited to the common practical aspects.

General Objective
After 3 days of interaction with the client and completing the case study, the
students will be able to know and understand the disease process and appropriate
medical and nursing management of acute pyelonephritis.

Specific Objectives
To properly conduct physical assessment to the client.
To understand the disease process, effects, management, treatment and
possible prevention.
Determine why certain management and medication are given and provided
for the condition.
Review the related anatomy and physiology with regards to the condition.
Provide health teaching to the patient about certain interventions in the
maintenance of health care.
To develop a rational plan of care for the client.
To evaluate the plan of care for future use.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Patients Profile
Name: P
Birthday:

May

Age: 25
17, Sex:

Attending Physician: Dr. R

Nationality:
Religion:

Roman

1990
Female
Filipino
Catholic
Address: Paso De Blas, City of Admission Date: August 1, 2015
Valenzuela
Diagnosis:
Acute Pyelonephritis

Discharge Date: August 5, 2015

Vital Signs:
BP: 90/60mmHg
38.8C
PR: 81 bpm
cpm

Temp:
RR: 28

Chief Complaint: abdominal pain

History of Present Illness:
2 days prior to consultation, patient has right lower quadrant pain accompanied
by fever, vomiting, loose bowel movement and anorexia. Biogesic and
mefenamic acid was taken. No relief was noted.
Past Medical History:
(-) DM, (+) UTI, cardiovascular disease, asthma, allergy
Family History:
(-) DM, cardiovascular disease, asthma, allergy
Personal and Social History:
Civil Status: Widowed
(-) Smoker
(+) Alcohol drinker
Obstetrical History:
G1P1(1001)
Menstrual History:
M - 12 yrs old
I - Irregular
D 7days
A 2 pads/day
S Dysmenorrhea

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Physical Assessment
(as of August 4, 2015)
Vital Signs

BP: 90/60mmHg
PR: 81 bpm

General Survey
Skin
HEENT
Chest
Heart

Awake, conscious, coherent

Temp: 38.8C
RR: 28 cpm

Good skin turgor, Capillary refill 2secs

Normal cephalic, (-) TPC, (-) CLAP, PPC
SCE, (-) retraction
Normal rate and rhythm, (-) murmur
Clear breath sounds
Flat, normal bowel sounds, (+) tenderness of right and
left lower quadrant

Lungs
Abdomen
Extremities
Neurological

grossly normal
GCS 15

Cranial Nerves Assessment

Olfactory Nerve
Optic Nerve
Oculomotor Nerve
Trochlear Nerve
Trigeminal Nerve
Abducens Nerve
Facial Nerve
Vestibulocochlear
Nerve
Glossopharyngeal
Nerve
Vagus Nerve
Spinal Accessory
Nerve
Hypoglossal Nerve

able
able
able
able
able
able
able
able

to
to
to
to
to
to
to
to

smell
see
move eyes
move eyes
perform teeth clenching and movement of mandible
move eyes outward
perform facial movements; able to taste
maintain balance

able to swallow; (+) gag reflex; able to taste

able to talk and swallow
able to move trapezius and sternocleidomastoid muscle
able to move tongue

Gordon's Functional Health Patterns

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

(upon hospitalization)
Health Perception and Health

Able to understand and cooperate with

Management

significant others and health care worker

Nutrition and Metabolism

regarding treatment
Diet includes vegetables and minimal meat
consumption
Water intake is >8 glasses a day

Elimination

Seldom consumes carbonated drinks

Defecates everyday

Activity and Exercise

Voids twice a day

Performs moderate

Cognition and Perception

activities
Good eyesight

Sleep and Rest

Self-perception

and

to

heavy

physical

Good sensation on both feet

Able to sleep adequately
Self- Able to communicate and tell stories about

concept
Roles and Relationships
Sexuality and Reproduction
Coping and Stress Tolerance

herself
Widowed
Patient denied sexual activity
Perception and stress coping strategies

Values and Belief

were assisted by significant others

Goes to church regularly

Anatomy and Physiology

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

URINARY SYSTEM
The urinary system, also known as the renal system, consists of the kidneys,
ureters, bladder, and the urethra. The purpose of the renal system is to eliminate
wastes from the body, regulate blood volume and blood pressure, control levels of
electrolytes and metabolites, and regulate blood pH.
Kidneys are a pair of bean-shaped organs, it filters metabolic wastes, excess
ions, and chemicals from the blood to form urine.
Ureters are a pair of tubes that carry urine from the kidneys to the urinary
bladder.
Uretero-vesical valves are valves prevent urine from flowing back towards the
kidneys.
Urinary bladder is a sac-like hollow organ used for the storage of urine. The
walls of the bladder allow it to stretch to hold anywhere from 600 to 800
milliliters of urine.
Urethra is the tube through which urine passes from the bladder to the
exterior of the body.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Nephrons are the functional units of the kidneys. There are normally approx.
one million (0.8 - 1.5 million) kidney nephrons in each of the two kidneys in the
body.
Renal Corpuscle is the part of the kidney nephron in which blood plasma is
filtered. The term "corpuscle" means "tiny" or "small" body. Glomerulus is a network
of small blood vessels called capillaries. Afferent arteriole brings blood into the
glomerulus. Efferent arteriole drains blood away from the glomerulus. The
(outgoing) efferent arteriole has a smaller diameter than the (incoming) afferent
arteriole. This difference in arteriole diameters helps to raise the blood pressure in
the glomerulus.
Bowman's capsule (also known as the Glomerular Capsule), which is the
double-walled epithelial cup within which the glomerulus is contained. Capsular
space is the area between the double-walls of Bowmans capsule. Glomerular
filtrate is the fluid filtered in the Bowmans capsule.
Renal Tubule is the part of the kidney nephron into which the glomerular
filtrate passes after it has reached the Bowman's capsule. Proximal convoluted
tubule (PCT) is the first part of the renal tubule.
The water and solutes that have passed through the proximal convoluted
tubule (PCT) enter the Loop of Henle, which consists of two portions - first the
descending limb of Henle, then the ascending limb of Henle. In order to pass
through the Loop of Henle, the water (and substances dissolved in it) pass from the
renal cortex into the renal medulla, then back to the renal cortex. When this fluid
returns to the renal cortex (via the ascending limb of Henle) it passes into the distal
convoluted tubule (DCT)

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

The distal convoluted tubules of many individual kidney nephrons converge onto a
single collecting duct. The fluid that has passed through the distal convoluted
tubules is drained into the collecting duct. Many collecting ducts join together to
form several hundred papillary ducts. There are typically about 30 papillary ducts
per renal papilla.
Renal Pelvis is a funnel-shaped basin (cavity) that receives the urine drained
from the kidney nephrons via the collecting ducts and then papillary ducts. Renal
Parenchyma is the soild part of the kidney, where the process of waste excretion
takes place.

Pathophysiology
RISK FACTORS:
Inability to empty the bladder
History of recent UTI
Women with sexual activity, diaphragm and
spermicide use

Introduction of bacteria to the urinary

tract
Adherence and colonization of bacteria in
the UT
Infection of urethra and

Bacteria ascends to ureters then the

Invasion of bacteria in the kidney and the

Impaired renal function

Inflammation of kidney / kidney infection

Production of
WBC to fight
infection

Flank pain and

tenderness
Headache
Chills
Fever
Malaise
Nausea and Vomiting

Frequent scanty
urination
Proteinuria
Hematuria

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Production of pus
as a result of
phagocytosis
Acute pyelonephritis results from bacterial invasion of the renal parenchyma.
Bacteria usually reach the kidney by ascending from the lower urinary tract. The
development of infection is influenced by bacterial factors and host factors.
Most bacterial data are derived from research with Escherichia coli, which accounts
for 70-90% of uncomplicated UTIs and 21-54% of complicated UTIs (ie, UTIs that are
secondary to anatomic or functional abnormalities that impair urinary tract drainage; are
associated with metabolic disorders; or involve unusual pathogens). A subset of E coli, the
uropathogenic E coli (UPEC), also termed extraintestinal pathogenic E coli (ExPEC), accounts
for most clinical isolates from UTIs.

Virulence factors
Adhesins have specific regions that attach to cell receptor epitopes in a lock-and-key
fashion. Mannose-sensitive adhesins (usually type 1 fimbriae) are present on essentially all E
coli. They contribute to colonization (eg, bladder, gut, mouth, vagina) and possibly
pathogenesis of infection; however, they also attach to polymorphonuclear neutrophils
(PMNs), leading to bacterial clearance.
Mannose-resistant adhesins permit the bacteria to attach to epithelial cells, thereby
resisting the cleansing action of urine flow and bladder emptying. They also allow the
bacteria to remain in close proximity to the epithelial cell, enhancing the activity of other
VFs.
The P fimbriae family of adhesins is epidemiologically associated with prostatitis,
pyelonephritis (70-90% of strains), and sepsis.
No single VF is sufficient or necessary to promote pathogenesis. Apparently, multiple VFs
are necessary to ensure pathogenesis, although adhesins play an important role.

Pathogens
As noted above, UPEC account for most uncomplicated pyelonephritis cases and a
significant portion of complicated pyelonephritis cases. The following microorganisms are
also commonly isolated:

Staphylococcus saprophyticus

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Klebsiella pneumonia
Proteus mirabilis
Enterococci
S aureus
Pseudomonas aeruginosa
Enterobacter species

Epithelial attachment and inflammatory response

Evidence suggests that the pathogenesis of pyelonephritis takes a 2-step path. First,
UPEC attaches to the epithelium and triggers an inflammatory response involving at least 2
receptors, glycosphingolipid (GSL) and Toll-like receptor 4 (TLR4). In the mouse model, GSL is
the primary receptor and TLR4 is recruited and is an important receptor for the release of
chemokines. When TLR4 is genetically absent, an asymptomatic carrier state develops in the
infected mice.
Second, as a result of the inflammatory response, chemokines (eg, interleukin-8 [IL8], which is chemotactic for PMNs) are released and attach to the neutrophil-activating
chemokine receptor 1 (CXCR1), allowing PMNs to cross the epithelial barrier into the urine.
Several other host factors militate against symptomatic UTI. Phagocytosis of bacteria
in urine is maximized at pH 6.5-7.5 and osmolality of 485 mOsm; values deviating from
these ranges lead to significantly reduced or absent phagocytosis. Other important factors
are the flushing action of urine flow in the ureter and bladder, the inhibition of attachment of
type 1 fimbriae E coli to uroepithelial cells by tubular cellsecreted Tamm-Horsfall protein,
and the inhibition of attachment by some surface mucopolysaccharides on the uroepithelial
cells.

Obstruction
Obstruction is the most important factor. It negates the flushing effect of urine flow;
allows urine to pool (urinary stasis), providing bacteria a medium in which to multiply; and
changes intrarenal blood flow, affecting neutrophil delivery.
Incomplete bladder emptying may be related to medication (eg, anticholinergics).
The spermicide nonoxynol-9 inhibits the growth of lactobacilli. Lactobacilli produce hydrogen
peroxide, which protects the vaginal ecosystem against pathogens. Frequent sexual
intercourse causes local mechanical trauma to the urethra in both partners.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Laboratory and Diagnostic Exams

Complete Blood Count
DATE: July 31, 2015
Test Name
White Blood Cell

22.9

Reference
Range
5.0-10.0

Neutrophils

89.2

40-60

3.1

1.3-3.5

1-6

Red Blood Cell

4.43

4.5-5.5

Hemoglobin

132

125-160

MCHC

328

320-360

Lymphocytes
Eosinophil

Result

Routine Urinalysis
DATE: July 31, 2015
Macroscopic Exam
RESULT
REMARKS
Color:
Transparency:
Reaction (ph)
S. Gravity
Protein

Light Yellow
Turbid
5.5
1.030
+2

Abnormal
High
High

Remarks

High

High

Low

REFERENCE
RANGE
Amber/Light
yellow
Transparent
4.6-8
1.015-1.025
Negative

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Sugar

Negative

Negative

Microscopic Exam
RESULT
REMARKS
WBC(PUS):
RBC:
Squamous E cell:
Mucus Threads:
Bacteria:

Color:
Transparency:
Reaction(ph)
S. Gravity

TNTC
Abnormal
15-20/hpf
Abnormal
Few
Few
Few
Automated Urinalysis
DATE: August 1, 2015
RESULT
REMARKS
Light Yellow
Turbid
5.5
1.015

Abnormal

REFERENCE
RANGE
0-2/hpf
0-2/hpf

REFERENCE
RANGE
Amber/Light
Yellow
Transparent
4.6-8
1.015-1.025

Whole Abdominal Ultrasound

DATE: August 3, 2015
The gallbladder, pancreas, and spleen are within normal findings. The
intrahepatic duct, common duct and portal vein are not dilated. The stomach
is physically distended. The wall is not thickened. The bowels are not dilated.
No sign of obstruction noted. Negative for abdominal mass or fluid with one
shadowing echo, measures 0.5cm noted on upper pole.
The right kidney measures 11.6x4.1cms. Negative for stones or masses.
The left kidney measures 11.7x4.8cms. Negative for stones or masses. Both
kidneys are within normal in size and echo pattern. Both upper collecting
systems are not dilated. Both corticomedullary junctions are distinct. The
ureters are not dilated. The urinary bladder is physiologically distended. The
wall is not thickened. Negative for stone or masses.
IMPRESSION:
Liver, Gallbladder, Pancreas, spleen, stomach, bowels left kidney, ureters and
Urinary bladder = Normal Findings.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Course in the Ward

On August 1, 2015, patient was hooked with PNSS 1L x 30 gtts/min. She was
given Ciprofloxacin 200 mg TIV, Paracetamol 500 mg q4 PRN for temperature of
more than 37.8C, and Paracetamol 300 mg TIV q4 PRN for temperature of more
than 39.8C. Abdominal ultrasound was performed, patient was for urine GS/CS,
under DAT, and TSB was carried out.

On August 2, 2015, patient was monitored accordingly, rendered with adequate

rest, and was kept safe and comfortable. Due medications was given and was
encouraged to verbalize needs and discomforts. Patient was on DAT and was
hooked to D5LR 1L x KVO. Still for urine GS/CS.

On August 3, 2015, patient was monitored accordingly, rendered with adequate

rest, and was kept safe and comfortable. She was on NPO and for abdominal
ultrasound.

On August 4, 2015, patient experienced abdominal pain. She was given

Ciprofloxacin 5000mg 1 tab BID x 7 days, Sambong capsule 1 cup TID x 2 weeks
and Buscopan 1 tab TID x pain.

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Discharge Planning
Medications
Instructed the client to take all the medications prescribed by the
doctor even if she feels better.
Cipfrofloxacin 500mg BID Q8 x 7days
Paracetamol 500mg 1tab Q4 PRN for temp >37.6C and pain.
Environment and Exercise
Advised the client to maintain a safe, clean and comfortable
environment
Advised the client to stay in a place with good ventilation
Encouraged client to do light exercises such as walking at least a week
after her hospitalization. Physical activity releases endorphins in the
body, which are the bodys natural pain killers.
Treatment
Oral antibiotics are used to treat patients with mild to moderate
infection.
Pyelonephritis can be treated by antibiotics. Antibiotics are generally
prescribed for a total of at least seven days. Part of this course of
treatment may be given in the hospital intravenously; the remainder
of the treatment may be taken at home in the form of pills.
Health Teaching

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

Advised the client practice good perineal hygiene by using vaginal

douche and avoid using strong soap and cosmetics on vaginal and
urethral area.
Advised the client to wipe her genitalia from front to back.
Advised the client to void whenever she has the urge to do so to
prevent urinary stasis which caused her pyelonephritis.
Advised the client to practice perineal hygiene before and after sexual
intercourse and to void after to prevent urinary tract infection.
Explained to the client the importance of drug compliance and that not
completing the prescribed medications can make infection come back.
It may also make a future infection harder to treat.
Advised client to follow activity restrictions, such as not driving or
operating machinery, as recommended by her healthcare provider,
especially when taking pain medicines.
Out- Patient
Reminded the client to go to the OPD of Valenzuela Medical Center 1
week after date of discharge.
Diet
There is no specific diet for kidney infection that a client is asked to
follow. However the consumption of certain foods should be avoided in
case you are suffering from an infection of this kind. Till the infection is
gone completely, it is best for the client to follow a diet that;
o Contains a low amount of sodium
o Limit the intake of protein
o Restricts the consumption of potassium-rich foods.
There are some foods that irritate the urinary tract and put a lot
pressure on the kidneys. Given below is a list of foods to avoid;
o Alcohol and Carbonated drinks
o Coffee or caffeinated beverages
o Cured meats like ham, bacon, and hotdogs
Encouraged the client to drink enough fluids, unless contraindicated as
drinking more fluids can flush harmful bacteria from the urinary tract.
Encouraged the client to drink cranberry juice or coconut juice as this
helps cleanse the body.
Spiritual
Encouraged client to pray according to her beliefs. Spiritual health
depends on the clients religion.