NUR 106 (MEDICAL SURGICAL NURSING 1-

STUDENT ACTIVITY SHEET LECTURE)

BS NURSING / THIRD YEAR
Session # 47

LESSON TITLE: CARE OF PATIENTS WITH Materials:

PYELONEPHRITIS Book, pen and notebook, index card/class list

LEARNING OUTCOMES: References:

1. Discuss the pathophysiologic responses to pyelonephritis
2. Assess the at-risk and sick adult client’s health
status/competence
3. Formulate with the client a plan of care to address needs
/problems and based on priority
4. Implement safe and quality nursing interventions with
client to address needs/ problems
5. Institute appropriate corrective actions to prevent
or minimize harm arising from adverse effects
6. Compare and contrast patients with pyelonephritis
with regard to cause, incidence, clinical
manifestations, management, and the significance of
preventive health care.
Hinkle, J. L., & Cheever, K. H. (2014). Brunner &
Suddarth's textbook of medical-surgical nursing
(Edition 13.). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Anef, C. D. R. D., & Faan, R. P. L. W. M. (2012).
Medical-Surgical Nursing: Patient-Centered
Collaborative Care, Single Volume (Ignatavicius,
Medical-Surgical Nursing, Single Vol) (7th ed.).
Saunders.
Fapwca, C. C. R. P. J. B. M., & DNSc Rn Bc, H. J.
H. (2008). Study Guide for Medical-Surgical
Nursing: Clinical Management for Positive
Outcomes (8th ed.). Saunders.

Porth, C., & Kunert, M. P. (2005).

Pathophysiology: concepts of altered health
states. 7th ed. Philadelphia: Lippincott Williams &
Wilkins.

Williams, L. S. 1., & Hopper, P. D. (2015).

Understanding medical surgical nursing. Fifth
edition. Philadelphia: F.A. Davis Company.

Lewis, S. M., Collier, I. C., & Heitkemper, M. M.

(1996). Medical-surgical nursing: Assessment and
management of clinical problems.

Lesson Preview (15 minutes)

Kidney infection (pyelonephritis) is a type of urinary tract infection (UTI) that generally begins in your urethra or bladder
and travels to one or both of your kidneys. A kidney infection requires prompt medical attention. To delve further into the
student’s perspective on this topic the instructor should raise questions regarding the topic
1. What are the causes of pyelonephritis?
Pyelonephritis is a bacterial infection of the renal pelvis, tubules and interstitial tissue of one or both kidneys. Causes involve
either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the blood
stream.

2. What are the different microorganisms involved in pyelonephritis?

The main cause of acute pyelonephritis is gram-negative bacteria, the most common being Escherichia coli. Other gram-
negative bacteria which cause acute pyelonephritis include Proteus, Klebsiella, and Enterobacter.

3. How will you assess a person that presents signs of pyelonephritis?

History and physical is the mainstay of evaluating acute pyelonephritis, laboratory and imaging studies can be helpful. A
urinary specimen should be obtained for a urinalysis.

MAIN LESSON (50 minutes)

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(Please read chapter 44 management of patients with renal disorders in your book Brunner and Suddharth’s
Medical-Surgical Nursing 13th edition)

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 Pyelonephritis is an infection involving the kidneys. Inflammation of the tissue accompanies the infectious process and
collecting system (including the renal pelvis). Typically the infection begins in the lower urinary tract and ascends upward.
Identification of infections and initiation of treatment is important to prevent the infection from getting worse. The most
common cause is bacterial infection, but fungi, protozoa, or viruses can also infect the kidney.

Urosepsis is a systemic infection arising from a urologic source. Its prompt diagnosis and effective treatment are critical
because it can lead to septic shock and death in 15% of cases unless promptly eradicated. Septic shock is the outcome of
unresolved bacteremia involving a gram-negative organism.

ASSESSMENT
Subjective Cues Objective cues
Acute: Acute:
 Chills  Fever
 Low back pain  Vomiting
 Flank pain  Leukocytosis
 Nausea  Bacteriuria
 Headache  Pyuria
 Malaise Chronic:
 Painful urination  Polyuria
 Pain and tenderness in the area of the costovertebral  Excessive thirst
angle  Weight loss may result
 Symptoms of lower urinary tract involvement, such as  Persistent and recurring infection may produce
urgency and frequency progressive scarring resulting in renal failure
Chronic:
 Fatigue
 Headache
 Poor appetite

MEDICAL MANAGEMENT- PHYSICIAN’S ORDER

Special Notation Laboratory/Diagnostic Medication IV fluid
examination
ACUTE PYELONEPHRITIS

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>Patients with acute >ultrasound or a CT scan >2 –week course of antibiotic IV for hydration
uncomplicated pyelonephritis – performed to locate an therapy – for patients with
are most often treated on an obstruction in the urinary acute uncomplicated
outpatient basis if they are not tract pyelonephritis (treated on an
exhibiting acute symptoms of >IV pyelogram – may be outpatient basis)
sepsis, dehydration, nausea, or indicated if functional  Fluoroquinolone
vomiting. and structural renal (ofloxacin)
>After initial antibiotic regimen, abnormalities are  Penicillin (amoxicillin)
the patient may need antibiotic suspected  Trimethoprim-
therapy for up to 6 weeks if a >To identify sites of sulfamethoxazole
relapse occurs. infection that may not be combination (Co-
>A follow-up urine culture is evaluated on CT or trimoxazole)
obtained 2 weeks after ultrasound
completion of antibiotic therapy  Radionuclide
to document clearing to the imaging with
infection. gallium citrate
>Hydration with oral or  Indium-111 WBC
parenteral fluids to help >Urine culture and
facilitate “flushing” of the sensitivity tests
urinary tract and reduces pain
and discomfort.

Chronic Pyelonephritis
>complications of chronic >IV urogram > long term antibiotic therapy > IV for hydration
pyelonephritis include end- >Creatinine clearance
stage kidney disease, >BUN
hypertension and formation of >creatinine levels
kidney stones.
>Long-term use of prophylactic
antimicrobial therapy may help
limit recurrence of infections
and kidney scarring
>Impaired kidney function alters
the excretion of antimicrobial
agents and necessitates careful
monitoring of kidney function.

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Nursing Diagnosis
Impaired urinary elimination
related to frequent urination,
urgency, and hesitancy.
Acute pain related to
inflammation and infection of
the urethra, bladder, and other
urinary tract structures.
NURSING CARE PLAN
Intervention Evaluation
 Assess the patient’s pattern of elimination. Patient achieves normal
 If patient is hospitalized, encourage fluids (3 to 4 L/day) urinary elimination
unless contraindicated. pattern, as evidenced
 Monitor and record intake and output. by absence sign of
 Encourage the client to void every 2-3 hours. urinary disorders
 Instruct the female client to wipe the area from front to back (urgency, oliguria,
and the avoidance of bath tubs. dysuria).
 Maintain an acidic environment of the bladder by the use of
agents such as Vit.C, Mandelamine (a urinary antiseptic)
when appropriate.
 Assess client’s description of pain such as quality, nature and Patient reports
severity of pain. satisfactory pain control
 Suggest use of non-pharmacological techniques as
appropriate.
 Apply a heating pad to the suprapubic area or lower back.
 Encouraged the use of a sitz bath.
 Instruct to avoid coffee, tea, alcohol, and sodas.
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Deficient knowledge related
tounfamiliarity with nature and treatment
of the disease
 Encouraged the client to finish all Client verbalizes knowledge of causes
prescribed antibiotics, even if and treatment, controls risk factors, and
symptoms resolve. completes medical treatment.
 Encouraging the reporting of
signs and symptoms of
recurrence.
 Teach the client about the
importance of preventing urinary
tract infection.

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to you. You can now ask questions and debate among yourselves. Write
the correct answer and correct/additional ratio in the space provided

Situation: the following questions pertains to the clinical decision making skills and knowledge of a registered nurse caring
for various patients with pyelonephritis

1. A client diagnosed with pyelonephritis asks the nurse "What is the disease?" The nurse's best response "Pyelonephritis
is an:
A. inflammation of the kidney and renal pelvis."
B. inflammation of the prostate gland."
C. inflammation of the urethra."
D. inflammation of the
bladder."

ANSWER: A
RATIO: Pyelonephritis is an inflammation of the kidney and renal pelvis. Prostatis is an inflammation of the prostate gland.
Urethritis is an inflammation of the urethra. Cystitis is an inflammation of the bladder.

2. The nurse is planning to teach the client about the signs and symptoms of a urinary tract infection. The nurse should
include: (Mark all that apply)
A. dysuria.
B. foul smelling cloudy urine.
C. urgency.
D. back pain.

ANSWER: A, B, C
RATIO: Signs and symptoms of urinary tract infections include dysuria, frequency, urgency, foul odor, pyuria, hematuria
and pain in the suprapubic area.

3. A male client is complaining of urinary frequency, dysuria, pain, fever and chills for the third time in 9 months. The
nurse should expect which diagnostic test to be ordered since this is the third infection in 9 months?
A. Urinalysis
B. X-ray of kidneys, ureter and bladder
C. Intravenous pyelography

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D. Computed tomography of the abdomen

ANSWER: C
RATIO: An intravenous pyelograph evaluates the structure and excretory function of the kidneys, ureter and bladder for
abnornalies such as vesicoureteral refex in people who have frequent infections. Urine culture and sensitivity is
appropriate but repetitive infections may indicate an underlying problem. Flat plate and CT scan of abdomen will only
evaluate structures of the kidneys, ureter and bladder.

4. Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis?
A. Jaundice and flank pain
B. Costovertebral angle tenderness and chills
C. Burning sensation on urination
D. Polyuria and
nocturia

ANSWER: B
RATIO: Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates
gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.

5. A client with pyelonephritis is being discharged from the hospital, and the nurse provides instructions to the client to
prevent recurrence. The nurse determines that the client understands the information that was given if the client states an
intention to:
A. increase fluids for 2 days if signs and symptoms of a urinary tract infection develop
B. take the prescribed antibiotics until all symptoms subside
C. return to the physician's office for scheduled follow-up urine cultures
D. decrease fluid intake if frequent urination
occurs

ANSWER: C
RATIO: The client with pyelonephritis should take the full course of antibiotic therapy that has been prescribed and return
to the physician's office for follow-up urine cultures if so instructed. The client should learn the signs and symptoms of a
urinary tract infection, and report them immediately if they occur. The client should also drink 3 L of fluid per day.

6. Which patient is at greatest risk for developing a urinary tract infection (UTI)?
A. A 35 y.o. woman with a fractured wrist
B. A 20 y.o. woman with asthma
C. A 50 y.o. postmenopausal woman
D. A 28 y.o. with angina

ANSWER: C
RATIO: Women are more prone to UTI's after menopause due to reduced estrogen levels. Reduced estrogen levels lead
to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don't
increase the risk of UTI.

7. Which of the following causes the majority of UTI’s in hospitalized patients?

A. Lack of fluid intake
B. Inadequate perineal care
C. Invasive procedures
D. Immunosuppression

ANSWER: C
RATIO: Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake
could cause concentration of urine, but wouldn't necessarily cause infection.

8. the most common early sign of kidney disease is:

A. Sodium retention
B. Elevated BUN level
C. Development of metabolic acidosis
D. Inability to dilute or concentrate
urine

ANSWER: B
RATIO: Increased BUN is usually an early indicator of decreased renal function.
9. The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis?
A. Myoglobinuria
B. Ketonuria
C. Pyuria
D. Low white blood cell (WBC) count

ANSWER: C
RATIO: Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits
fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low,
as indicated in option D. Ketonuria indicates a diabetic state.

10. When examining a female client’s genitourinary system, Nurse Sandy assesses for tenderness at the costovertebral
angle by placing the left hand over this area and striking it with the right fist. Normally, this percussion technique produces
which sound?
A. A flat sound
B. A dull sound

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C. Hyperresonance
D. Tympany

ANSWER: B
RATIO: Percussion over the costovertebral angle normally produces a dull, thudding sound, which is soft to moderately
loud with a moderate pitch and duration. This sound occurs over less dense, mostly fluid-filled matter, such as the kidneys,
liver, and spleen.

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: THE MUDDIEST POINT

This strategy provides a structure for students to record their own comprehension and summarize their learning. It also
gives teachers opportunity to identify areas that need re-teaching, and areas of student interest.

In today’s session, what was least clear to you?

Kung ngano wala nalang ko nag artista

(for the next lesson Please read chapter 47 management of patients with female reproductive disorders in your
book Brunner and Suddharth’s Medical-Surgical Nursing 13th edition)

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