MEDICAL SURGICAL NURSING

SEMINAR ON
URINARY TRACT INFECTIONS AND
NEPHRITIS

SUBMITTED TO: SUBMITTED BY:

MS.SINITHA K B GARGI M P

NURSING TUTOR 1ST YEAR MSC NURSING

AL-SHIFA COLLEGE OF NURSING AL-SHIFA COLLEGE OF NURSING

SUBMITTED ON: 01.02.2021

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CENTRAL OBJECTIVE

At the end of class group will get adequate knowledge about “URINARY TRACT
INFECTIONS AND NEPHRITIS”

SPECIFIC OBJECTIVE

At the end of class group will be able to:

 Desrcibe about urinary tract infection.

 Mention the causes and risk factors of UTI.
 List down the classification of UTI.
 Briefly describe about the classification of lower and upper UTI and its management in
detail.
 Discuss the nursing management of UTI.
 Describe about acute and chronic glomerulonephritis and its management.

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 URINARY TRACT INFECTIONS AND NEPHRITIS

Subject : MEDICAL SURGICAL NURSING Group :

Topic : URINARY TRACT INFECTIONS AND NEPHRITIS Place :

Method of teaching :Lecture-cum-discussion Date :

Teaching AV aid : Time :

Name of student teacher: GARGI M P Duration:

Name of the evaluator :MS. SINITHA

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 INTRODUCTION
Diseases of the kidney and urinary tract are ‘silent killers’. Acute renal disorders develop suddenly and
nearly all can be diagnosed and cured; only a few of them leave a permanent damage. Urinary tract
infections are the most common bacterial infections in women. Renal and urologic disorders encompass a
wide spectrum of problems. The diverse causes of these disorders may involve infectious, immunologic,
obstructive, metabolic and neurologic mechanisms.

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 URINARY TRACT INFECTIONS
Urinary tract infections are caused by pathogenic microorganisms in the urinary tract (the normal
urinary tract is sterile above the urethra).UTIs are generally classified as infections involving
upper and lower urinary tract.

INCIDENCE
 UTI are common in women rather than in men. During their life time atleast 20% of
womens develop at least one UTI. The incident raises to 50% in women over the age of
80.
 UTI are common in persons older than 65 years of age than in younger adults.
 About 50% of causes of UTI in women accounts for E.choli infection.

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RISK FACTORS OF URINARY TRACT INFECTION

Factors Increasing Urinary Stasis

 Extrinsic obstruction (tumor, fibrosis compressing urinary tract)

 Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH)
 Urinary retention (including neurogenic bladder and low bladder wall compliance)
 Renal impairment

Foreign Bodies

 Urinary tract calculi

 Catheters (indwelling, external condom catheter, ureteral stent, nephros-Tomy tube,
intermittent catheterization)
 Urinary tract instrumentation (cystoscopy, urodynamics)

Anatomic Factors

 Congenital defects leading to obstruction or urinary stasis

 Fistula (abnormal opening) exposing urinary stream to skin, vagina, or fecal Stream
 Shorter female urethra and colonization from normal vaginal flora
 Obesity

Factors Compromising Immune Response

 Aging
 Human immunodeficiency virus infection
 Diabetes mellitus

Functional Disorders

 Constipation
 Voiding dysfunction with detrusor sphincter dysynergia

Other Factors

 Pregnancy

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  Hypoestrogenic state (menopause)
 Multiple sex partners (women)
 Use of spermicidal agents or contraceptive diaphragm (women)
 Poor personal hygiene
 Habitual delay of urination (“nurse’s bladder,” “teacher’s bladder”)

ETIOLOGY

 Bacterial infection:The common bacteria causing urinary tract infections are:

o Escherichia coli
o Enterococcus
o Klebseilla
o Enterobacter
o Proteus
o Pseudomonas
o Staphylococcus
o Serratia
o Candida Albicans
 Hospital acquired infections(HAIs) previously called nosocomial infections.Catheter
acquired urinary tract infections(CAUTIs) are the most common HAIs and are caused
by development of bacterial biofilms that are found on the catheters inner surface.
 Obesity
 Multiple sexual partners.
 Injury to renal tract such as obstruction of the ureter,damage caused by renal stones or
renal scars.
 Human immuno deficiency virus infections.

CLASSIFICATION OF URINARY TRACT INFECTIONS

Urinary tract infections(UTI) are classified by location:

 LOWER UTI: It includes bladder and structure below bladder.

 Cystitis

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  Prostatis
 Urethritis
 UPPER UTI: It includes the kidneys and ureters.
 Acute pyelonephritis
 Chronic pyelonephritis
 Renal abcess
 Interstitial nephritis
 Perirenal abcess

Classification based on complications:

 UNCOMPLICATED LOWER OR UPPER UTI

 Community acquired infection
 COMPLICATED LOWER OR UPPER UTI
 Nosocomial infection associated with catheterization

LOWER URINARY TRACT INFECTIONS

Several mechanisms maintain the sterility of the bladder: the physical barrier of the urethra, urine
flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and
antiadherent effects mediated by the mucosal cells of the bladder. Abnormalities or dysfunctions
of these mechanisms are contributing factors to lower UTIs.

PATHOPHYSIOLOGY

For infection to occur,bacteria must gain acess to the bladder, attach to and colonize the
epithelium of the urinary tract to avoid being washed out with voiding,evade host defense
mechanisms,and intiate inflammation.Most UTIs result from fecal organisms that ascend from
the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.

BACTERIAL INVASION OF THE URINARY TRACT

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  By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria
removal), the bladder can clear itself of even large numbers of bacteria.
 Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective
effect against various bacteria.
 The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive
layer between the bladder and the urine.
 GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and tryptophan
metabolites).
 The normal bacterial flora of the vagina and urethral area also interfere with adherence of
Escherichia coli (the most common microorganism causing UT1).
 Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria.

REFLUX
 An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the
reflux (backward flow) of urine from the urethra into the bladder .
 With coughing,sneezing, or straining, the bladder pressure rises, which may force urine from the
bladder into the urethra.
 When the pressure returns to normal, the urine flows back into the bladder, bringing into the
bladder bacteria from the anterior portions of the urethra.
 Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The
urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the
incidence of infection in postmenopausal women.
 Reflux is most often noted, however, in young children. Treatment is based on its severity.
 Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into
one or both ureters.
 Normally, the ureterovesical junction prevents urine from traveling back into the ureter.
 The ureters tunnel into the bladder wall so that the bladder musculature compresses a small
portion of the ureter during normal voiding.
 When the urethrovesical valve is impaired by congenital causes or ureteral abnormalities,the
bacteria may reach and eventually destroy the kidneys.

UROPATHOGENIC BACTERIA

 Bacteriuria is generally defined as morethan 105 colonies of bacteria per milliliter of urine.
 Because urine samples(especially in women) are commonly contaminated by the bacteria
normally present in the urethral area,bacterial count exceeding 10 5 colonies/ml of clean-catch

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 midstream urine is the measure that distinguishes true bacteriuria can be defined as 10 5
colonies/ml urine.
 Community-acquired UTIs are among the most common bacterial infections in women.
 The organisms most frequently responsible for UTIs are those normally found in the lower
gastrointestinal tract.In a large scale study study of the types and prevalence of organisms of
patients with UTIs in both the community and hospital setting.
 E.coli is decreasing in comparison to previous observations,especially in males and in patients
with indwelling bladder catheters,who instead had higher rates of Pseudomonas and
enterococcus organisms than females and non catheterized patients.

ROUTES OF INFECTION

There are three well recognized routes by which bacteria enter the urinary tract:

 Up the urethra(ascending infection)

 Through the blood stream(hematogenous spread)
 By means of a fistula(direct extension)

The most common route of infection is transurethral,in which bacteria (often from fecal
contamination) colonize the periurethral area and subsequently enter the bladder by means of the
urethra.In women,the short urethra offers little resistance to the movement of uropathogenic
bacteria.Sexual intercourse or the massage of the urethra forces the bacteria up into the
bladder.This accounts for the increased incidence of UTIs in sexually active women.Bacteria
may also enter the urinary tract by means of the blood(hematogenous spread) from a distant site
of infection or through direst extension by way of a fistula from the intestinal tract.

CLINICAL MANIFESTATIONS

A variety of signs and symptoms are associated with UTI.About half of patients with bacteriuria
have no symptoms.

Lower urinary tract symptoms are classified under 2 headings:

 Emptying symptoms
 Storage symptoms

Emptying symptoms

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Hesitancy

 Difficulty starting urine stream

 Delay between initiation of urination (because of urethral sphincter relaxation) and
beginning of flow of urine.
 Diminished urinary stream

Intermittency

 Interruption of urinary stream while voiding

Postvoid dribbling

 Urine loss after completion of voiding

Urinary retention or incomplete emptying

 Inability to empty urine from bladder

 Caused by atonic bladder or obstruction of urethra
 Can be acute or chronic

Dysuria

 Painful or difficult urination

Storage Symptoms

Urinary frequency

 >8 times in 24-hr period

 Often200 mL each voiding

Urgency

 Sudden, strong, or intense desire to void immediately

 Commonly accompanied by frequency
Incontinence

 Involuntary or accidental urine loss or leakage

Nocturia

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  Awakened by urge to void 2 or more times during sleep
 May be diurnal or nocturnal depending on sleep schedule
Nocturnal enuresis

 Adults: loss of urine during sleep

Symptoms of upper urinary tract includes:
 Dysuria: Refers to difficult urination.
 Frequent urination morethan every 2 hours.
 Urgency
 Suprapubic discomfort or pressure.
 Hematuria:Presence of blood in urine.Urine may also contains some sediments in urine
which give it a cloudy appearance.
 Flank pain
 Chills
 Nausea and vomiting.

ASSESSMENT AND DIAGNOSTIC FINDING

 History and physical examination.
 Urine analysis
 Urine for culture and sensitivity
 Imaging studies of urinary tract
 CT urogram
 Intravenous pyelogram
 CT/IVP
 Cystoscopy
 Ultrasound

URINE ANALYSIS AND URINE CULTURE

The urinalysis provides important clinical information on kidney function and helps diagnose other
diseases, such as diabetes. The urine culture determines if bacteria are present in the urine, as well as their
strains and concentration. Urine culture and sensitivity also identify the antimicrobial therapy that is best
suited for the particular strains identified, taking into consideration the antibiotics that have the best rate
of resolution in that particular geographic region. Appropriate evaluation of any abnormality can assist in
detecting serious underlying diseases.

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Urine examination includes the following

 Urine color
 Urine clarity and odor
 Urine pH and specific gravity
 Tests to detect protein, glucose, and ketone bodies in the urine (proteinuria, glycosuria, and
ketonuria, respectively)
 Microscopic examination of the urine sediment after centrifuging to detect RBCs (hematuria),
white blood cells, casts (cylindruria), crystals (crystalluria), pus (pyuria), and bacteria
(bacteriuria)

URINE CULTURE

Urine culture remain the gold standard in documenting a UTI and can identify the specific organism
present. Because of the high probability that organism in young women with their first UTI is E.coli,
cultures are often omitted. The following groups of patients should have urine cutures obtained when
bacteriuria is present:

 All men (because of likelihood of structural or functional abnormalities)

 All children
 Women wityh a history of compromised immune function or renal problems.
 Pateints with diabetes mellitus.
 Patient who have undergone recent instrumentation like catheterization of urinary tract.
 Patient with prolonged or persistant symptoms.
 Patient with three or more UTIs in the past year.
 Pregnant women
 Post menopausal women
 Patients who are sexually active or have new partner.

CELLULAR STUDIES

Microscopic hematuria(greater than 4 red blood cells )per high-power field is present in about
half of patients with acute infection.Pyuria(greater than 4 white blood cells per high power field)

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occurs in all patients wit UTI;however,it is not specific for bacterial infection.Pyuria can also
been seen with kidney stones,interstitial nephritis,and renal tuberculosis.

TESTING METHODS

Multistrip dipstick testing for WBCs ,known as the leukocytes esterase test,and nitrite
testing(Greiss nitrite reduction test) are common.If the leukocyte esterase test is positive,it is
assumed that the patient has pyuria and should be treated.The nitrite test is considered positive if
bacteria that reduces normal urinary nitrates to nitrites are present.

GENERAL ULTRASONOGRAPHY

Ultrasonography is a noninvasive procedure that uses sound waves passed into the body through a
transducer to detect abnormalities of internal tissues and organs. Structures of the urinary system create
characteristic ultrasonographic images. Abnormalities such as fluid accumulation, masses, congenital
malformations, changes in organ size, or obstructions can be identified. During the test, the lower
abdomen and genitalia may need to be exposed. Ultrasonography requires a full bladder; therefore, fluid
intake should b e encouraged before the procedure. Because of its sensitivity, ultrasonography has
replaced many other tests as the initial diagnostic findings

INTRAVENOUS PYELOGRAPHY

Intravenous pyelography includes various tests such as excretory urography,intravenous

pyelography(IVP),and infusion drip pyelography.A radio opaque contrast agent is administered
intravenously.AAn IVP shows the kidneys,ureter,and bladder via x-ray imaging as dye moves
through the upper and then lower urinary system.

CYSTOGRAPHY

Cystography aids in evaluating vesicoureteral reflux (backflow of urine from the bladder into one or both
ureters) and assessing the patient for bladder injury.A catheter is inserted into the bladder and a contrast
agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder
perforation stemming from bladder injury, but such leakage is usually harmless. Cystography can also be
performed with simultaneous pressure recordings inside the bladder.

VOIDING CYSTOURETHROGRAPHY

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Voiding cystourethrography uses fluoroscopy to visualize the lower urinary tract and asses urine
storage in the bladder. It is commonly used as diagnostic tool to identify vesico urethral
reflux.SA uretral catheter is inserted and a contrast agent is instilled into the bladder. When the
bladder is full and patient feels urge to void, the catheter is removed ,and the patient voids.

MEDICAL MANAGEMENT
Medical management of UTIs typically involves:

 Pharmacologic therapy
 Patient education.

Nurse is a key figure in teaching the patient about medication regimens and infection prevention
measures.

ACUTE PHARMACOLOGIC THERAPY

 The ideal treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract
with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast
infections. (yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents
that affect vaginal flora.Yeast vaginitis often causes more symptoms and is more difficult and
costly to treat than the original UTI.)
 Additionally, the antibacterial agent should be affordable and should produce few adverse effects
and low resistance. Because the organism in initial,uncomplicated UTIs in women is most likely
E. Coli or other fecal flora, the agent should be effective against these organisms.
 Various treatment regimens have been successful in treating uncomplicated lower UTIs in
women: single-dose administration,short-course (3 to 4 days) medication regimens, or 7-to 10-
day therapeutic courses.
 The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs because
about 80% of cases are cured after 3 days of treatment.
 In a complicated UTI (ie, pyelonephritis), the general treatment of choice is usually a
cephalosporin or an ampicillin/aminoglycoside combination.
 Patients in institutional settings may require 7 to 10 days of medication for the treatment to be
effective.
 Other commonly used medications include:
 Trimethoprim-

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  Sulfamethoxazole (I’MP-SMZ Bactrim, Septra)
 nitrofurantoin(Macrodantin, Furadantin).

 Occasionally, medications such as ampicillin or amoxicillin are used, but E. Coli organisms have
developed resistance to these agents.
 Recent clinical trials comparing the use of TMP-SMZ and the fluoroquinolone
ciprofloxacin(Cipro) found ciprofloxacin to be significantly more effective in community-based
patients and in nursing home residents.
 Levofloxacin (Levaquin), another fluoroquinolone, is a good choice for short-course therapy of
uncomplicated, mild to moderate UTI.
 Clinical trial data show high patient compliance with the 3-day regimen (95,6%) and a high
eradication rate for all pathogens (96.4%).
 Before using levofloxacin in patients with complicated UTIs, the causative pathogen should be
identified.
 Levofloxacin is used only when generic and less costly antibiotics are likely to be ineffective.
 Nitrofurantoin should not be used in patients with renal insufficiency because it is ineffective at
glomerular filtration rates(GFR) of less than 50 mL/min and may cause peripheral neuropathy.
 Phenazopyridine (Pyridium), a urinary analgesic, may be prescribed to relieve the discomfort
associated with the infection.
 Regardless of the regimen prescribed, the patient is instructed to take all the doses prescribed,
even if relief of symptoms occurs promptly.
 Longer medication courses are indicated for men, pregnant women and women with
pyelonephritis and other types of complicated UTIs.
 In pregnant women, amoxicillin, ampicillin,or an oral cephalosporin is used for 7 to 10 days.

LONG TERM PHARMACOLOGIC THERAPY

 Although brief pharmacologic treatment of UTI for 3 days is usually adequate in women,
infection recurs in about 20% of women treated for uncomplicated UTI.
 Infections that recur within 2 weeks after therapy (referred to as a relapse) do so because
organisms of the original offending strain remain in the vagina.
 Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial
treatment was inadequate or administered for too short a time.
 Recurrent infections in men are usually due to persistence of the same organism; further
evaluation and treatment are indicated.

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  Reinfection of the female patient with new bacteria is the reason for more than 90% of recurrent
UTIs in women.
 If the diagnostic evaluation reveals no structural abnormalities in the Urinary tract, the woman
with recurrent UTIs may be instructed to begin treatment on her own whenever symptoms occur
and to fever occurs, or the number of treatment episodes exceeds four in a 6 month period.
 This patient may be taught to use dip-slide culture devices to detect bacteria.

 If infection recurs after completing antimicrobial therapy,another short course (3 to 4 days) of

full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent
may be prescribed.
 Other options include a dose of an antimicrobial agent after sexual intercourse, a dose at
bedtime, or a dose every other night or three times per week.
 Long-term use of antimicrobial agents decreases the risk of reinfections and may be indicated in
patients with recurrent infections.
 If recurrence is caused by persistent bacteria from preceding infections, the cause (ie, kidney
stone, abscess), if known, must be treated.
 After treatment and sterilization of the urine, low-dose preventive therapy (trimethoprim with or
without sulfamethoxazole) each night at bedtime is often prescribed.
 Evidence about the effectiveness of daily intake of cranberry extract or cranberry juice to prevent
UTIs in women is conflicting, although most randomized studies point to a decrease in UTIs in
women consuming daily cranberry juice (Kontiokari,Sundqvist&Nuutinen, 2001).

PATIENT EDUCATION

 HYGEINE
 Shower rather than bathe in tub because ba ctreria in bath tub may enter the
urethra.
 After each bowel movement,clean the perineum and the urethral meatus from
front to back.This will help reduce concentrations of pathogens at the urethral
opening and,in women,the vaginal opening.
 FLUID INTAKE
 Drink liberal amount of water daily to flush out bacteria.
 Avoid coffee,tea,colas,alcohol and other fluids that are urinary tract irritants.

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  VOIDING HABITS
 Void every 2 to 3 hours during the day and completely empty the bladder.This
prevents overdistension of the bladder and compromised blood supply to the
bladder wall.Both predispose the patient to UTI.
 In women void immediately after the intercourse.Take the prescribed single dose
of an antimicrobial agent after sexual intercourse.
 THERAPY
 Take medication exactly as prescribed
 If bacteria continue to appear in the urine, long term antimicrobial therapy may be
required to prevent colonization of the periurethral area and recurrence of infection. The
medication should be taken after emptyng the bladder just before going to bed to ensure
adequate concentration of the medication during the overnight period.
 For recurrent infection, consider acidification of the urine through ascorbic acid (vitamin
C). 1,000 mg daily, or cranberry juice.
 If prescribed, test urine for bacteria with recommended test devices, such as dip slides
(Microstis), as follows:
o Wash around the urethral meatus several times, using different washcloths.
o Collect a midstream urine specimen.
o Remove a slide from its container, dip it into the urine sample,and return it to the
container.
o Incubate the slide at room temperature according to product directions.
o Read the results by comparing the slide with the colony densitychart provided
with the product.
o Begin therapy as directed, and complete the full prescribed course of medication.
o Notify the health care provider if fever occurs or if signs and symptoms persist.
 Consult the health care provider regularly for follow-up, recurrence of symptoms, or infections
nonresponsive to treatment.

UPPER URINARY TRACT INFECTIONS

ACUTE PYELONEPHRITIS

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 Pyelonephritis is a bacterial infection of the renal pelvis, tubules,and interstitial tissue of one or both
kidneys. Upper UTIs are associated with the antibody coating of the bacteria in the urine.(This occurs in
the renal medulla; when the bacteria are excreted in the urine, the immunofluorescent test can detect the
antibody coating.) Bacteria reach the bladder by means of the urethra and ascend to the kidney. Although
the kidneys receive 20% to 25% of the cardiac output, bacteria rarely reach the kidneys from the blood:
fewer than 3% of cases are due to hematogenous spread(Warren et al., 1999).

Pyelonephritis is frequently secondary to ureterovesical reflux, in which an

incompetent ureterovesical valve allows the urine to back up (reflux) into the ureters . Urinary tract
obstruction (which increases the susceptibility of the kidneys to infection), bladder tumors, strictures,
benign prostatic hyperplasia, and urinary stones are some of the other causes. Pyelonephritis may be acute
or chronic.Patients with acute pyelonephritis usually have enlarged kidneys with interstitial infltrations of
infammatory cells. Abscesses may be noted on the renal capsule and at the corticomedullary junction.
Eventually, atrophy and destruction of tubules and theglomeruli may result. When pyelonephritis
becomes chronic, the kidneys become scarred, contracted, and nonfunctioning.

CLINICAL MANIFESTATIONS

The patients with acute pyelonephritis appears acutely ill with chills ans fever,leukocytosis,bacteriuria
and pyuria,flank pain and CVA tenderness.In addition symptoms of lower urinary tract involvement,such
as dysuria and frequency are common.

ASSESSMENT AND DIAGNOSTIC FINDINGS

 An ultrasound study or a CT scan may be performed to locate any obstruction in the urinary tract.
Relief of obstruction is essential to save the kidney from destruction.
 An IVP is rarely indicated during acute pyelonephritis because findings are normal in up to75%
of patients.
 Radionuclide imaging with gallium citrate and indium-111 (In”)-labeled WBCs may be useful to
identity sites of infection that may not be visualized on CT scan or ultrasound.
 Urine culture and sensitivity tests are performed to determine the causative organism so that
appropriate antimicrobial agents can be prescribed.

MEDICAL MANAGEMENT

 Patients with acute uncomplicated pyelonephritis are usually treated as outpatients if they are not
dehydrated, not experiencing nausea or vomiting, and not showing signs or symptom of sepsis. In

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 addition, they must be responsible and reliable to ensure that all medications are taken as
prescribed.
 Other patients, including all pregnant women, may be hospitalized for at least 2 or 3 days of
parenteral therapy.
 Oral agents may be substituted once the patient is afebrile and showing clinical improvement.

PHARMACOLOGICAL THERAPY

 For outpatients ,a 2 week course of antibiotics is recommended because renal parenchymal

disease is more difficult to irradicate rather than mucosal bladder infections.
 Commonly prescribed agents include TMP-SMZ,ciprofloxacin,gentamycin with or without
ampicillin,or a third-generation cephalosporin.
 This medications must be used with great caution if th patient has renal or liver dysfunction.
 A possible problem in acute pyelonephritis treatment is a chronic or recurring symptomless
infection persisting for months or years.
 After the initial antibiotic regimen,the patient may need antibiotic therapy for upto 6 weeks if
evidence of relapse is seen.
 A follow up urine culture is done 2 weeks after completion of antibiotic therapy to document
clearing of the infection..

CHRONIC PYELONEPHRITIS

Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.Recent evidences

suggest that chronic pyelonephritis is decreasing as a common causes for ESRD.

CLINICAL MANIFESTATIONS

The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute
exacerbation occurs.

Other symptoms include:

 Fatigue
 Head ache
 Poor apetite
 Polyuria

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  Excessive thirst
 Weight loss

ASSESSMENT AND DIAGNOSTIC FINDINGS

The extent of the disease is assessed by an intravenous urogram and measurements of creatinine
clearance and BUN .Bacteria if detected in urine are irradicated if possible.

COMPLICATIONS

Complications of chronic pyelonephritis include ESRD(from progressive loss of nephrons

secondary to chronic inflammation and scarring),hypertension and formation of kidney
stones(from chronic infection with urea-splitting organisms)

MEDICAL MANAGEMENT

The choice of antimicrobial agent is based on which pathogen is identified through urine
culture.If the urine cannot be made bacteria free,nitrofurantoin or TMP-SMZ may be used to
suppress bacterial growth.Impaired renal function alters the excretion of antimicrobial agents and
necessiates careful monitoring of renal function.

NURSING MANAGEMENT

PLANNING

The overall goals are that the patient with a UTI will have :

1. Relief from bothersome LUTS

2. Prevention of upper urinary tract involvement
3. Prevention of recurrence.

NURSING IMPLEMENTATION

1) Health promotion
2) Acute intervention
3) Ambulatory and home care

HEALTH PROMOTION

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  It is important to recognize individuals who are at risk for a UTI.
 These people include debilitated persons, older adults, patients who are
immunocompromised (eg, cancer, human immunodeficiency virus (HIV), diabetes
mellitus), and patients treated with immunosuppressive drugs or corticosteroids.
 Health promotion activities, particularly for these individuals, can help decrease the
frequency of infections and provide for early detection of infection.Health promotion
activities include teaching preventive measures such as
o Emptying the bladder regularly and completely,
o Evacuating the bowel regularly,
o Wiping the perineal area from front to back after urination and defecation.
o Drinking an adequate amount of liquid each day.
o To estimate the amount of fluid intake a person should have in 24 hours,
take the person’s weight in pounds and divide number in half.The result is
the number of ounces of fluid a person should have per day.Thus a 150
pound person would require 75 oz/day.The person will obtain about
20%of this fluid from food,which leaves 60oz (1775ml)obtained by
drinking or just over seven 8-oz glasses of fliud.
o Daily intake of cranberry juice or cranberry tablets or capsules may reduce
the number of UTIs.It is thought that enzymes found in cranberries inhibit
attachment of urinary pathogens to the bladder wall.
 All patients undergoing instrumentation of the urinary tract are at risk for developing
an HAI UTI.
 Avoidance of unnecessary catherization and early removal of indwelling catheters are
the most effective means for reducing HAI UTIs.
 Always follow aseptic technique during these procedures.
 Wash your hands before and after contact with each patient.
 Wear gloves for care involving the urinary system.
 When a catheter has been inserted,use special measures for the prevention of
infection.

ACUTE INTERVENTION

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  Acute intervention for a patient with a UTI includes ensuring adequate fluid intake if it is not
contraindicated.
 Maintaining adequate fluid intake may be difficult because of the patient’s perception that fluid
intake will worsen the discomfort and urinary frequency associated with a UTI.
 Tell patients that fluids will increase frequency of urination at first but will also dilute the urine,
making the bladder less irritable.
 Fluids will help flush out bacteria before they have a chance to colonize in the bladder.
 Caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages should be
avoided because they are potential bladder irritants.
 Application of local heat to the suprapubic area or lower back may relieve the discomfort
associated with a UTI.
 Advise the patient to apply a heating pad (turned to its lowest setting) against the back or
suprapubic area.
 A warm shower or sitting in a tub of warm water filled above the waist can also provide
temporary relief.
 Instruct the patient about the prescribed drug therapy,including side effects. Emphasize the
importance of taking the full course of antibiotics.
 Often patients stop antibiotic therapy once symptoms disappear.
 This can lead to inadequate treatment and recurrence of infection or bacterial resistance to
antibiotics.
 Sometimes a second drug or a reduced dosage of drug is ordered after the initial course to
suppress bacterial growth in patients susceptible to recurrent UTI.
 Instruct the patient to monitor for signs of improvement (e.g., cloudy urine becomes clear) and a
decrease in or cessation of symptoms.
 Teach patients to promptly report any of the following to their health care provider: (1)
persistence of bothersome LUTS beyond the antibiotic treatment course, (2) onset of flank pain,
or (3) fever.

AMBULATORY AND HOME CARE

 Home care for the patient with a UTI should emphasize the importance of adhering to the drug
regimen.
 Your responsibility is to teach the patient and caregiver about the need for ongoing care.

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  This includes taking antimicrobial drugs as ordered, maintaining adequate daily fluid intake,
voiding regularly (approximately every 3 to 4 hours), urinating before and after intercourse, and
temporarily discontinuing the use of a diaphragm.
 If treatment is complete and the symptoms are still present, instruct the patient to get follow-up
care.
 Recurrent symptoms because of bacterial persistence or inadequate treatment typically occur
within 1 to 2 weeks after completion of therapy.
 If the patient has followed the treatment regimen, a relapse indicates the need for further
evaluation.

EVALUATION

The expected outcomes are that the patient with a UTI :

 Will experience normal urinary elimination patterns

 Report relief of bothersome urinary tract symptoms
 Verbalize knowledge of treatment regimen

EVIDENCE BASED PRACTICE OF UTI

Are Prophylactic Antibiotics Effective for Recurrent Urinary Tract Infection?

Clinical Question

In women , is long-term prophylactic antibiotic use more effective than Placebo in preventing recurrent
urinary tract infections ?

Best Available Evidence

Systematic review of randomized controlled trials (RCTs)

Critical Appraisal and Synthesis of Evidence

 10 RCTs (N = 430 women) comparing antibiotic use for 6 to 12 months against a placebo for
recurrent urinary tract infections (UTI).
 Recurrence is defined as three or more UTI episodes during a 12-month period.
 Antibiotics reduced the number of UTI recurrences in pre- and postmenopausal women with
recurrent UTI.

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  Antibiotic group had higher incidence of side effects, including vaginal itching, skin rash, and
nausea.

Conclusions

Prophylactic antibiotic administration in women who experience recurrent UTIs reduces recurrence.

Implications for Nursing Practice

 Patient treatment preference should be considered when weighing the discomfort of recurrent
UTIs and the adverse effects of prophylactic antibiotics.
 UTI prophylaxis for longer than 12 months has not been studied.

Reference for Evidence

Albert X, Huertas I, Pereiró I, et al: Antibiotics for preventing recurrent urinary tract infection in non-
pregnant women, Cochrane Database Syst Rev3: 2004.

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NEPHRITIS
A variety of diseases can affect the glomerular capillaries,including acute an dchronic
glomerulonephritis,rapidly progressive glomerulonephritis and nephrotic syndrome.In all of
these disorders the glomerular capillaries are primarily involved.

ACUTE GLOMERULONEPHRITIS

Glommerulonephritis is the inflammation of glomerular capillaries.Acute glomerulonephritis is

primarly a disease of children older than 2 years of age,but it can occur at nearly any age.

CAUSES OF GLOMERULONEPHRITIS

Infections

 Poststreptococcal Glomerulonephritis
 GN may develop 1-2 wk after a streptococcal throat infection or rarely, a skin
infection(impetigo).
 Antibodies (Ab) to strep antigen (Ag) develop and the Ag-Ab deposit in the
glomeruli, causing inflammation
 Infective endocarditis
 Bacteria can cause an infection of one or more of the heart valves .
 People at risk include those with a heart defect, such as a damaged or artificial
heartvalve.
 Bacterial endocarditis is associated with GN,but the exact cause is not known.
 Viral infections
 Viral infections can trigger GN.
 Common viruses include human immunodeficiency virus (HIV) and hepatitis B
and hepatitis C viruses.

Immune Diseases

 Systemic lupus erythematosus (SLE)

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  Autoimmune disorder characterized by the involvement of several tissues and
organs,particularly joints, skin, and kidneys.
 GN frequently occurs in SLE and has a poor prognosis
 Scleroderma
 Disease of unknown etiology characterized by widespread alterations of
connective tissue and by vascular lesions in many organs.
 In the kidney, vascular lesions are associated with fibrosis. Severity of renal
involvement varies.
 Goodpasture syndrome
 Autoimmune disorder that causes lung and kidney disease
 Causes bleeding into the lungs and GN.
 IgA nephropathy
 Results from deposits of immunoglobulin A(IgA) in the glomeruli.
 Characterized by recurrent episodes of hematuria

Vasculitis

 Polyarteritis
 Autoimmune disease that affects small and medium blood vessels.
 . Can affect any organ but common in heart,kidneys, and intestines
 Wegener’s granulomatosis
 •Form of vasculitis affecting small and medium blood vessels
 Most commonly affects kidneys, lungs, and upper respiratory tract

Conditions Causing Scarring of Glomeruli

 Diabetic nephropathy
 Primary cause of end-stage kidney disease in the United States
 Microvascular changes of diffuse glomerulosclerosis involving thickening of the
glomerular basement membrane
 Hypertension
 Nephrosclerosis is a complication of hypertension
 GN can also cause hypertension.
 Focal segmental glomeruloscelerosis
 Characterized by scattered scarring of some glomerulosclerosis of the glomeruli

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  . May result from another disease or occur for unknown reasons

Other Causes

 Amyloidosis
 • Caused by infiltration of tissues with amyloid(hyaline substance)
 Hyaline bodies consist largely of protein.
 Kidney involvement is common, and proteinuria is often the first clinical
manifestation
 Illegal drug use
 People who use these drugs are at increased risk for GN

GOOD PASTURE SYNDROME

Good pasture syndrome is an autoimmune disease characterized by circulating antibodies against

glomerular and alveolar basement membrane.Damage to the kidneys and lungs results when binding of
the antibody causes an inflammatory reaction mediated by compliment action.Good pasture syndrome is a
rare disease that is mostly found in young male smokers.The clinical manifestations include flu-like
symptoms with pulmonary symptoms such as cough,mild shortness of breath,hemoptysis,crackles,rhonci
and pulmonary insufficiency.

PATHOPHYSIOLOGY

Antigen(group A beta-hemolytic streptococcus)

Antigen antibody product

Deposition of antigen-antibody complex in glomerulus

Increased production of epithelial cells lining the glomerulus

Leukocytes infiltrate the glomerulus

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 Thickening of the glomerular filtration membrane

Scarring and loss of glomerular filtration memebrane

Dicreased glomerular infiltration rate(GFR)

CLINICAL MANIFESTATIONS

 Cola coloured urine because RBCs and protein plugs or casts

 Proteinuria
 Anemic
 Edema and hypertension
 Headache,malaise and flank pain
 Dyspnea
 Engorged neck vein
 Cardiomegally
 Pulmonary edema
 Confusion

ASSESSESSMENT AND DIAGNOSTIC FINDINGS

 Kidney biopsy
 Electron microscopy
 Urine routine studies
 Cystoscopy
 Ultrasonography
 Intravenous pyelography

COMPLICATIONS

 Hypertensive encephalopathy:Hypertensive encephalopathy is a medical emergency,and

therapy is directed towards reducing blood pressure without affecting kidney function.
 Optic neuropathy
 ESRD
 Heart failure
 Pulmonary edema

MANAGEMENT

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  Management consists primarily of treating symptoms, attempting to preserve kidney function,
and treating complications promptly.
 Pharmacologic therapy depends on the cause of acute glomerulonephritis.
 If residual streptococcal infection is suspected, penicillin is the agent of choice; however, other
antibiotic agents may be prescribed.
 Corticosteroids and immunosuppressant medications may be prescribed for patients with rapidly
streptococcal progressive acute glomerulonephritis, but in most cases of post streptococcal acute
glomerulonephritis,theses medications are of no value and may actually worsen the fliud
retention and hypertension.
 Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN)
develop. Sodium is restricted when the patient has hypertension, edema, and heart failure loop
diuretic medications and antihypertensive agents may be prescribed to control hypertension.
 Prolonged bed rest has little value and does not alter long-term outcomes.

NURSING MANAGEMENT

Although most patients with acute uncomplicated glomerulonephritis are treated as outpatients, nursing
care is important no matter what the setting. In a hospital setting, carbohydrates are given liberally to
provide energy and reduce the catabolism of protein. Intake and output are carefully measured and
recorded.Fluids are given according to the patients fuild losses and daily body weight.Insensible fluid loss
through the respiratory and GI tracts (500 to 1,000 mL) is considered when estimating fluid
loss.Diuresis begins about 1 week after the onset of symptoms with a decrease in edema and blood
pressure. Proteinuria and microscopic hematuria may persist for many monthsand some patients may go
on to develop chronic glomerulonephritis. Other nursing interventions focus primarily on patient
education for safe and effective self-care at home.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.:Patient education is directed toward maintaining kidney function and
preventing complications, fluid and diet restrictions must be reviewed with the patient to avoid worsening
of edema and hypertension. The patient is instructed to notify the physician if symptoms of renal failure
occur (eg, fatigue, nausea, vomiting, diminishing urine output) or at the first sign of any infection.
Information is given verbally and in writing.

Continuing Care: The importance of follow-up evaluations of nlood pressure, urinalysis for protein, and
serum BUN and creatinine levels to determine if the disease has progressed is stressed to the patient. A
referral for home care may be indicated; a visit from a home care nurse provides an opportunity for
careful assessment of the patient’s progress and detection of early signs and symptoms of renal
insufficiency. If corticoseroids, immunosuppressant agents, or antibiotic medications are prescribed, the
home care nurse or nurse in the outpatient setting uses the opportunity to review the dosage, desired
actions,and adverse effects of medications and the precautions to be followed.

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 CHRONIC GLOMERULONEPHRITIS

Chronic glomerlonephritis is a syndrome that reflects the end stage of glomerular inflammatory
disease.Most types of glomerunephritis and nephrotic syndrome can eventually lead to chronic
glomerulonephritis.Some people who develop chronic glomerulonephritis have no history of
kidney disease.Frequently the cause of glomerulonephritis is not found.Infrequently it is
inherited disorder.

PATHOPHYSIOLOGY

 Chronic glomerulonephritis may be due to repeated episodes of acute glomerulonephritis,

hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, or
hemodynamically mediated glomerular sclerosis.
 The kidneys are reduced to as little as one-fifth their normal size (consisting largely of fibrous
tissue).
 The cortex shrinks to a layer 1 to 2 mm thick or less.
 Bands 0f scar tissue distort the remaining cortex, making the surface of the kidney rough and
irregular.
 Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are
thickened.
 The result is severe glomerular damage that results in ESRD.

CLINICAL MANIFESTATIONS

 The symptoms of chronic glomerulonephritis vary. Some patients with severe disease have no
symptoms at all for many years.
 Their condition may be discovered when hypertension or elevated BUN and serum creatinine
levels are detected.
 The diagnosis may be suggested during a routine eye examination when vascular changes or
retinal hemorrhages are found.
 he first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.Many
patients complain that their feet are swollen at night.
 Most patients also have general symptoms, such as loss of weight and strength, increasing
irritability, and an increased need to urinate at night (nocturia).
 Headaches, dizziness and digestive disturbances are common.As chronic glomerulonephritis
progresses, signs and symptoms of renal insufficiency and chronic renal failure may develop.
 The patient appears poorly nourished, with a yellow-gray pigmentation of the skin and periorbital
and peripheral (dependent) edema.
 Blood pressure may be normal or severely elevated. .
 Retinal findings include hemorrhage, exudate, narrowed tortuous arterioles, and papilledema.
Mucous membranes are pale because of anemia.
 Cardiomegaly, a gallop rhythm, distended neck veins,and other signs and symptoms of heart
failure be present.

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  Crackles can be heard in the lungs. Peripheral neuropathy with diminished deep tendon reflexes
and neurosensory changes occurs late in the disease.
 The patient becomes confused and demonstrates a limited attention span.
 An additional late finding includes evidence of pericarditis with a pericardial friction rub and
pulsusparadoxus (difference in blood pressure during inspiration and expiration of greater than 10
mm Hg).

ASSESSMENT AND DIAGNOSTIC FINDINGS

 A number of laboratory abnormalities occur.

 Urinalysis reveals a fixed specific gravity of about 1.010, variable proteinuria, and urinary casts
(protein plugs secreted by damaged kidney tubules).
 As renal failure progresses and the GFR falls below 50 mL/min, the following changes occur:
 Hyperkalemia due to decreased potassium excretion, acidosis, catabolism, and excessive
potassium intake from food and medications.
 Metabolic acidosis from decreased acid secretion by the kidney and inability to regenerate
bicarbonate.
 Anemia secondary to decreased erythropoiesis (production of RBCs).
 Hypoalbuminemia with edema secondary to protein loss through the damaged glomerular
membrane.
 Increased serum phosphorus level due to decreased renal excretion of phosphorus
 Decreased serum calcium level (calcium binds to phosphorus to compensate for elevated serum
phosphorus levels).
 Hypermagnesemia from decreased excretion and inadvertent ingestion of antacids containing
magnesium.
 Impaired nerve conduction due to electrolyte abnormalities and uremia.
 Chest x-rays may show cardiac enlargement and pulmonary edema.
 The electrocardiogram may be normal or may indicat left ventricular hypertrophy associated with
hypertension and signs of electrolyte disturbances, such as tall, tented (or peaked)
 Waves associated with hyperkalemia. Serum markers, including vascular endothelial growth
factor and thrombospondin-1, are being evaluated for their reliability in assessing renal
disease.

MEDICAL MANAGEMENT

 Symptoms guide the course of treatment for the patient with chronic glomerulonephritis.
 If the patient has hypertension, the blood pressure is reduced with sodium and water restriction,
antihypertensive agents, or both.
 Weight is monitored daily, and diuretic medications are prescribed to treat fluid overload.
 Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good
nutritional status.
 Adequate calories are also important to spare protein for tissue growth and repair.
 UTIs must be treated promptly to prevent further renal damage.

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  Initiation of dialysis is considered early in the course of the disease to keep the patient in optimal
physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of
complications of renal failure.
 The course of dialysis is smoother if treatment begins before the patient develops significant
complications.

NURSING MANAGEMENT

If the patient is hospitalized or seen by the nurse in the home,the nurse observes the patient for changes in
fluid and electrolyte status and for signs and symptoms of deterioration of renal function. Changes in fluid
and electrolyte status and in cardiac and neurologic status are reported promptly to the physician.Anxiety
levels are often extremely high for both the patient and family. Throughout the course of the disease and
treatment, the nurse gives emotional support by providing opportunities for the patient and family to
verbalize their concerns, have their questions answered, and explore their options.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care. The nurse has a major role in teaching the patient and family about the
prescribed treatment plan and the risks associated with noncompliance. Instructions to the patient include
explanations and scheduling for follow-up evaluations: blood pressure, urinalysis for protein and casts,
and blood studies of BUN and creatinine levels. If long-term dialysis is needed, the patient and family are
taught about the procedure,how to care for the access site, dietary restrictions, and other necessary
lifestyle modifications. Periodic hospitalization, visits to the outpatient clinic or office, and home care
referrals provide the nurse in each setting with the opportunity for careful assessment of the patient’s
progress and continued education about changes to report to the primary health care provider (worsening
signs and symptoms of renal failure, such as nausea, vomiting, and diminished urine output). Specific
teaching may include explanations about recommended diet and fluid modifications and medications
(purpose, desired effects, adverse effects, dosage, and administration schedule).

Continuing Care. Periodic evaluation of creatinine clearance and serum BUN and creatinine levels is
carried out to assess residual renal function and the need for dialysis or transplantation. If dialysis is
initiated, the patient and family will require considerable assistance and support in dealing with therapy
and its long-term implications. The patient and family are reminded of the importance of participation in
health promotion activities, including health screening. The patient is instructed to inform all health care
providers about the diagnosis of glomerulonephritis so that all medical management, including
pharmacologic therapy, is based on altered renal function.

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 REFERENCE
1) Suzanne C.Smeltz,BrendaG.bare,”Brunner and Suddarth’s Textbook of MEDICAL
SURGICAL NURSING”,Lippincott Williams & Wilkins,10th edition,Page-1310-1320
2) Lewis,Dirksen,Heitkemper,Bucher,”Lewis’s Medical-Surgical Nursing Assessment and
Management of Clinical Problems”, Elsevier publications,Second South Asia Edition,Page-
1116-1127

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