Conditions Affecting Urinary Elimination

1. Pyelonephritis (PN): acute or chronic inflammation due to bacterial infection of the parenchyma and renal pelvis: 95% of cases caused by gram-negative enteric bacilli (Escherichia coli); occurs more frequently in women.
1. Pathophysiology: inflammation of renal medulla or lining of the renal pelvis —» nephron destruction; hypertrophy of nephrons needed to maintain urine output —> impaired sodium reabsorption (salt wasting); inability to concentrate urine; progressive renal failure; hypertension (two-thirds of all cases).
2. Risk factors:
   1. Urinary obstruction (tumors, prostate).
   2. Cystitis.
   3. Neurogenic bladder.
   4. Pregnancy.
   5. Catheterization, cystoscopy.
3. Assessment:
   1. Subjective data:
      1. Pain: flank-one or both sides; back; dysuria; headache.
      2. Loss of appetite; weight loss.
      3. Night sweats; chills.
      4. Urination: frequency, urgency.
   2. Objective data:
      1. Fever; shaking chills.
      2. Lab data:
         1. Blood-polymorphonuclear leukocytosis >ll,000/mm⁵.
         2. Urine-leukocytosis, hematuria, white blood cell casts, proteinuria (<3 g in 24 hr), positive cultures; specific gravity-normal or increased with acute PN, decreased with chronic PN; cloudy; foul smelling.
   3. Intravenous pyelogram  (IVP) - may manifest structural changes.
4. Analysis/nursing diagnosis:
   1. Altered urinary elimination related to kidney disease.
   2. Pain related to dysuria and kidney damage.
   3. Hyperthermia related to inflammation.
   4. Risk for fluid volume excess related to renal failure.
5. Nursing care plan/implementation:
   1. Goal: combat infection, prevent recurrence, alleviate symptoms.
      1. Medications:
         1. Antibiotics, urinary antiseptics, and/or sulfonamides appropriate for causative organism; also reduce pain.
         2. Analgesics for pain - phenazopyridine (Pyridium); stronger if calculi present.
         3. Antipyretics for fever - acetaminophen (Tylenol).
      2. Fluids: 1500 - 2000 mL/day to flush kidneys, relieve dysuria, reduce fever, prevent dehydration.
      3. Observe hydration status: I&O (output minimum 1500 mL/24 hr); daily weight; urine - check each voiding for protein, 0 blood, specific gravity; vital signs q4h to monitor for hypertension, tachycardia; skin turgor.
      4. Hygiene: meticulous perineal care; cleanse with soap and water; antibiotic ointment may be used around urinary meatus with retention catheter.
      5. Cooling measures: tepid sponging.
      6. Diet: sufficient calories and protein to prevent malnutrition; sodium supplement as ordered. Acid-ash to prevent renal calculus.
   2. Goal: promote physical and emotional rest.
      1. Activity: bed rest or as tolerated - depends on whether anemia or fever is present; encourage activities of daily living as tolerated.
      2. Emotional Support: encourage expression of fears (possible renal failure, dialysis); provide diversional activities; include family in care; answer questions.
   3. Goal: health teaching.
   1. Medications: take regularly to maintain blood level; side effects.
   2. Personal care: perineal hygiene; avoid urethral contamination (wiping perineum front to back); avoid tub baths.
   3. Possible recurrence with pregnancy.
   4. Monitoring daily weight.
6. Evaluation/outcome criteria:
1. Normal renal function (minimum 1500 mL urine/24 hr).
2. Blood pressure within normal range.
3. No recurrence of symptoms.