Upper Urinary Tract Infections PDF

10/19/23, 3:42 AM Realizeit for Student Upper Urinary Tract Infections Upper UTIs are much less common than those in the lower urinary tract. Acute pyelonephritis and chronic pyelonephritis are thought to be the most likely type, with interstitial nephritis (inflammation of the kidney) and kidney...

10/19/23, 3:42 AM Realizeit for Student Upper Urinary Tract Infections Upper UTIs are much less common than those in the lower urinary tract. Acute pyelonephritis and chronic pyelonephritis are thought to be the most likely type, with interstitial nephritis (inflammation of the kidney) and kidney abscesses also a potential cause. Upper UTIs are a common cause of urosepsis (Freeman et al., 2017). 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 bloodstream. Bacteria from a bladder infection can ascend into the kidney, resulting in pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection (see Fig. 49-1 ), because static urine provides a good medium for bacterial growth. Bladder or prostate tumors, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses. Pyelonephritis may be acute or chronic. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 1/6 10/19/23, 3:42 AM Realizeit for Student Figure 49-1 • Mechanisms of urethrovesical and ureterovesical reflux may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A. When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacterialaden urine. Acute Pyelonephritis Clinical Manifestations https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 2/6 10/19/23, 3:42 AM Realizeit for Student Acute pyelonephritis is the cause of more than 25,000 hospital admissions annually and usually leads to enlargement of the kidneys with interstitial infiltrations of inflammatory cells (Freeman et al., 2017; Norris, 2019). Abscesses may be noted on or within the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. Clinical Manifestations The patient with acute pyelonephritis has chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle. In addition, symptoms of lower urinary tract involvement, such as urgency and frequency, are common. Assessment and Diagnostic Findings An ultrasound study or a CT scan may be performed to locate an obstruction in the urinary tract. Relief of obstruction is essential to prevent complications and eventual kidney damage. An IV pyelogram may be indicated if functional and structural renal abnormalities are suspected (Fischbach & Fischbach, 2018). Radionuclide imaging with gallium citrate and indium-111 (111In)–labeled WBCs may be useful to identify 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 (Fischbach & Fischbach, 2018). Medical Management Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting acute symptoms of sepsis, dehydration, nausea, or vomiting. Patients treated on an outpatient basis must be willing and able to take their medications as prescribed. For outpatients, a 2-week course of antibiotic agents is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections. Commonly prescribed agents include many of the same medications prescribed for the treatment of UTIs. Following acute pyelonephritis treatment, the patient may develop a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if a relapse occurs. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 3/6 10/19/23, 3:42 AM Realizeit for Student Hydration with oral or parenteral fluids is essential in all patients with UTIs when there is adequate kidney function. Hydration helps facilitate “flushing” of the urinary tract and reduces pain and discomfort. Chronic Pyelonephritis Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis. When pyelonephritis becomes chronic, the kidneys become scarred, contracted, and nonfunctioning. Chronic pyelonephritis is a cause of chronic kidney disease that can result in the need for renal replacement therapy (RRT) such as transplantation or dialysis. Clinical Manifestations The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, resulting in chronic kidney disease Assessment and Diagnostic Findings The extent of the disease is assessed by an IV urogram and measurements of creatinine clearance, blood urea nitrogen, and creatinine levels (Fischbach & Fischbach, 2018). Complications Complications of chronic pyelonephritis include end-stage kidney disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of renal calculi (from chronic infection with urea-splitting organisms). Medical Management Bacteria, if detected in the urine, are eradicated if possible. 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, especially if the medications are potentially toxic to the kidneys. Nursing Management The patient may require hospitalization or may be treated as an outpatient. When the patient requires hospitalization, fluid intake and output are carefully measured and recorded. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. The nurse assesses the patient’s temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 4/6 10/19/23, 3:42 AM Realizeit for Student Patient education focuses on prevention of further infection by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking antimicrobial medications exactly as prescribed is stressed, as is the need for keeping follow-up appointments. Adult Voiding Dysfunction The micturition (voiding or urination) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying. If voiding dysfunction goes undetected and untreated, the upper urinary system may be compromised. Both neurogenic and nonneurogenic disorders can cause adult voiding dysfunction. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 5/6 10/19/23, 3:42 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 6/6