Which condition or laboratory result supports a diagnosis of pyelonephritis?

Pyelonephritis is an infection of the kidneys and is caused by a bacterial infection of the lower urinary tract, such as a urinary tract infection.  Escherichia coli is considered the most common organism causing pyelonephritis. 

Pyelonephritis can be categorized as acute or chronic. Acute pyelonephritis is referred to as an active bacterial infection of the kidneys while the chronic type is repeated infection in the upper urinary tract caused by structural deformities, obstruction, reflux, or urinary stasis. 

The classic signs and symptoms of this condition include:

• Flank pain
• Dysuria
• Polyuria
• Urinary urgency
• Urinary frequency
• Malaise
• Fever
• Nausea and vomiting

Complications of pyelonephritis include kidney failure and renal scarring. Pyelonephritis can become life-threatening if untreated and bacteria spreads to the bloodstream causing sepsis.

Urinalysis and urine culture tests are indicated when pyelonephritis is suspected and may show bacteriuria, pyuria, and hematuria. Ultrasound tests and CT scans may be done to determine structural abnormalities, renal abscesses, renal scarring, impaired renal function, or obstructions. 

The Nursing Process

Patients with mild symptoms are treated with antibiotics for 7 to 14 days in an outpatient setting while patients with severe symptoms require hospitalization and IV antibiotic therapy. Surgical interventions like pyelolithotomy, nephrectomy (for severe cases), or ureteral diversion may be indicated to correct structural issues, drain abscesses, or remove an obstruction. 

Nurses support patients with pyelonephritis by providing accurate information about individualized treatment plans including medications, nutrition, and fluid therapies. Nurses are vital in educating patients on how to prevent a recurrence of pyelonephritis.

Nursing Care Plans Related to Pyelonephritis 

Acute Pain Care Plan

The most distinctive symptoms of acute pyelonephritis include pain in the back or flank area. The patient may describe suprapubic symptoms of heaviness, pressure, or discomfort.

Nursing Diagnosis: Acute Pain

Related to:

• Inflammation and infection of the urinary tract

As evidenced by:

• Reports of pain/burning/discomfort when urinating
• Dysuria
• Polyuria
• Facial grimace
• Guarding behavior 
• Spasm in the bladder and lower back 

Expected Outcomes:

• The patient will verbalize an absence of flank pain and dysuria. 
• The patient will report satisfactory pain control at a level of less than 3 on a scale of 0-10.

Acute Pain Assessment

1. Assess the patient’s urinary symptoms.
Proper assessment of urinary symptoms can help diagnose pyelonephritis. Common manifestations of pyelonephritis include dysuria, polyuria, frequency, and urgency. Changes in urine odor and color may also indicate bacteriuria.

2. Assess the patient’s description of pain.
Pain associated with pyelonephritis may be described as heaviness, pressure, or discomfort of the back, abdomen, or flank area with or without radiation to the groin. Assess for dysuria or burning with urination.

3. Assess the flanks and costovertebral angle (CVA).
Enlargement, asymmetry, redness, and edema of the flank area can indicate inflammation. Tenderness and discomfort upon percussion on these areas can also indicate infection or inflammation.

4. Monitor laboratory tests as indicated.
Urinalysis indicating pyelonephritis will show a positive leukocyte esterase, presence of white blood cells, bacteria, and occasional protein and red blood cells. A urine culture will help identify specific organisms that are causing the infection. Serum kidney tests like BUN and creatinine can help determine worsening or improving kidney function.

Acute Pain Interventions

1. Administer medications as indicated.
Antibiotics are prescribed to treat the infection. Antipyretics like acetaminophen are prescribed to help reduce fever and pain.

2. Increase fluids as ordered.
Adequate fluid intake at 2 liters per day will help with urine dilution, promote renal blood flow, reduce bladder irritation, and flush bacteria from the urinary tract.

3. Encourage the patient to avoid urinary tract irritants.
Sodas, spices, tea, alcoholic beverages, and coffee are considered urinary tract irritants and should be avoided.

4. Encourage the patient to void frequently.
Frequent voiding will help to empty the bladder, avoiding bladder distention, reducing urine stasis, preventing reinfection, and lowering bacterial count. Patients may be hesitant to void due to pain but should be educated on these reasons.

5. Assist the patient in using non-pharmacologic techniques for pain management.
Alternative therapies like positioning, heat, relaxation, and guided imagery can help decrease pain, offer distraction, and promote comfort for the patient.

6. Educate the patient about the disease process, prognosis, and treatment regimen.
Patient education is vital to ensure understanding of the disease process and prevention. Stress the importance of completing antibiotic therapy to prevent antibiotic resistance and reinfection.

Hyperthermia Care Plan 

Fever or hyperthermia is a common symptom of pyelonephritis. The triad signs of this acute infection include fever, costovertebral angle pain, and nausea and vomiting, though these may not occur in all patients or all together.

Nursing Diagnosis: Hyperthermia

Related to:

• Inflammatory process secondary to pyelonephritis
• Infectious process secondary to pyelonephritis

As evidenced by:

• Increased body temperature above the normal range
• Chills
• Warm, flushed skin
• Diaphoresis
• Tachycardia 
• Tachypnea

Expected Outcomes:

• The patient will maintain core body temperature within the normal range. 
• The patient will maintain vital signs within normal limits. 

Hyperthermia Assessment

1. Assess for signs of hyperthermia.
Assess signs and symptoms of hyperthermia including weakness, tachycardia, headache, irritability, and malaise to determine potential complications or deterioration.

2. Assess and monitor vital signs.
Changes in vital signs including tachycardia and hypertension indicate progression of hyperthermia.

3. Assess intake, output, and signs of dehydration.
Hyperthermia can result in dehydration. Signs and symptoms of dehydration include thirst, poor skin turgor, dry oral membranes, weak and fast pulse, decreased urine output, and increased urine concentration.

Hyperthermia Interventions

1. Provide a tepid sponge bath as needed
A sponge bath with tepid water will reduce fever by dilating the superficial blood vessels, ultimately releasing heat and lowering body temperature. Do not induce shivering as this is the body’s attempt to increase temperature.

2. Encourage adequate fluid intake.
Adequate fluid intake will help prevent dehydration, which is precipitated by the increase in body temperature.

3. Maintain bed rest.
Adequate rest allows the reduction of metabolic demands and oxygen consumption, resulting in a decrease in body temperature.

4. Administer antipyretic medications as indicated.
Antipyretic medications reduce prostaglandin synthesis to lower body temperature.

Impaired Urinary Elimination Care Plan

Impaired urinary elimination can be a result of sensory impairment, physical abnormality, or a secondary cause of another disorder. This can happen in patients with pyelonephritis due to symptoms of the condition such as frequent urination, a strong, persistent urge to urinate, and urinary hesitancy.

Nursing Diagnosis: Impaired Urinary Elimination

Related to: 

• Kidney infection and inflammation
• Weakened bladder muscles 
• Anatomic obstruction 

As evidenced by:

• Urinary hesitancy
• Urinary retention
• Urinary incontinence
• Urinary urgency
• Dysuria
• Frequent voiding
• Nocturia

Expected Outcomes:

• The patient will achieve a normal urinary elimination pattern, as evidenced by the absence of urinary frequency, urgency, and hesitancy.
• The patient will establish lifestyle techniques to prevent urinary infections.

Impaired Urinary Elimination Assessment

1. Assess the patient’s elimination patterns.
The patient’s elimination patterns can offer insight into causes of infection such as incontinence, delayed urination, or incomplete urination.

2. Assess the patient’s hygiene practices.
Inquire about the patient’s understanding of hygiene in relation to urinary elimination. The patient should be instructed to urinate after sexual activity, wipe front to back after bathroom use, and clean the perineal area daily to avoid infections of the urinary tract.

Impaired Urinary Elimination Interventions

1. Measure intake and output accurately.
A record of the patient’s intake and output can help determine changes in urine characteristics (amount and concentration), which can indicate the progression of pyelonephritis.

2. Instruct the patient to void every 2-3 hours.
This will help to empty the bladder and prevent the buildup of urine. Bladder training helps in reducing urine leakage and a sense of urgency by increasing the amount of fluid the bladder holds and the time between emptying of the bladder.

3. Check for distention with a bladder scanner.
This can help determine bladder distention or incomplete emptying after urination.

4. Encourage increased fluid intake.
Adequate fluid intake promotes hydration, increases urine production, and flushes out bacteria from the urinary tract system. Patients with incontinence issues can be hesitant to drink enough which creates an environment for dehydration and urinary infection.

5. Facilitate a comfortable voiding position, making use of urinals or bedpans as needed.
Discomfort can affect the patient’s elimination patterns. Offer urinary devices frequently for the patient who cannot communicate to support urination.

References and Sources

1. Acute Pyelonephritis. Copyright © 1994-2022 by WebMD LLC. https://emedicine.medscape.com/article/245559-overview
2. Belyayeva M, Jeong JM. Acute Pyelonephritis. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519537/
3. Bono MJ, Reygaert WC, Doerr C. Urinary Tract Infection (Nursing) [Updated 2021 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568701/
4. Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
5. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
6. Pyelonephritis: Kidney infection. National Kidney and Urologic Diseases Information Clearinghouse. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-infection-pyelonephritis

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