‫كلية التمريض كلية معتمدة‬

Prepared by
Dr/ Asmaa Said Ali
Lecturer in Medical Surgical Nursing
Department

Faculty of Nursing
Ain-Shams University
2014/2015

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Outlines:
[Link]

[Link]/ Risks

[Link] and classifications

[Link] and symptoms

[Link] measures

[Link] of pyelonephritis

[Link] Management

[Link] management

[Link] management for patient with urinary tract infection

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 Urinary tract infection

A urinary tract infection (UTI) (also known as acute cystitis or bladder

infection) is an infection that affects part of the urinary tract. When it affects the
lower urinary tract it is known as a simple cystitis (a bladder infection) and when it
affects the upper urinary tract it is known as pyelonephritis (a kidney infection).
Symptoms from a lower urinary tract include painful urination and either frequent
urination or urge to urinate (or both), while those of pyelonephritis include fever
and flank pain in addition to the symptoms of a lower UTI. In the elderly and the
very young, symptoms may be vague or non-specific. The main causal agent of
both types is Escherichia coli, though other bacteria, viruses or fungi may rarely be
the cause.

Types of urinary tract infections

1. Upper urinary tract infection
2. Lower urinary tract infections

Upper urinary tract infection includes

A. Glomeriolonephritis
B. Pyelonephritis
C. Ureteritis

Lower urinary tract infections as

A. Cystitis
B. Urethritis

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 I. Upper urinary tract infection
1. Glomeriolonephritis

Glomerulonephritis, also known as glomerular nephritis, is a term used to refer

to several renal diseases (usually affecting both kidneys). Many of the diseases are
characterised by inflammation either of the glomeruli or small blood vessels in the
kidneys, hence the name,[1] but not all diseases necessarily have an inflammatory
component.

Causes of glomeriolonephritis:
Many conditions can cause glomerulonephritis; however, sometimes the cause is
unknown. Conditions that can lead to inflammation of the kidneys' glomeruli may
include:

Infections
 Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a
week or two after recovery from a strep throat infection or, rarely, a skin
infection (impetigo). To fight the infection, your body produces extra
antibodies that may eventually settle in the glomeruli, causing inflammation.
Children are more likely to develop post-streptococcal glomerulonephritis than
are adults, and they're also more likely to recover quickly.

 Bacterial endocarditis. Bacteria occasionally can spread through your

bloodstream and lodge in your heart, causing an infection of one or more of
your heart valves. You're at greater risk of this condition if you have a heart
defect, such as a damaged or artificial heart valve. Bacterial endocarditis is
associated with glomerular disease, but the exact connection between the two is
unclear.
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 Viral infections. Viral infections, such as the human immunodeficiency virus
(HIV), hepatitis B and hepatitis C, may trigger glomerulonephritis.

Immune diseases

 Systemic lupus erythematous (Lupus). A chronic inflammatory disease,

lupus can affect many parts of your body, including your skin, joints, kidneys,
blood cells, heart and lungs.

Vasculitis

 Polyarteritis. This form of vasculitis affects small and medium blood vessels
in many parts of your body, such as your heart, kidneys and intestines.

 Wegener's granulomatosis. This form of vasculitis affects small and medium

blood vessels in your lungs, upper airways and kidneys.

Conditions likely to cause scarring of the glomeruli

 High blood pressure. High blood pressure can damage your kidneys and
impair their ability to function normally. Glomerulonephritis can also lead to
high blood pressure because it reduces kidney function and may influence how
your kidneys handle sodium.

 Diabetic kidney disease. Diabetic kidney disease (diabetic nephropathy) can

affect anyone with diabetes. Diabetic nephropathy usually takes years to
develop. Good control of blood sugar levels and blood pressure may prevent or
slow kidney damage.

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 Focal segmental glomerulosclerosis. Characterized by scattered scarring of
some of the glomeruli, this condition may result from another disease or occur
for no known reason.

Nephrotic syndrome

The nephrotic syndrome is characterised by the finding of edema in a patient that

has increased protein in the urine and decreased protein in the blood, with
increased fat in the blood. Inflammation that affects the cells surrounding the
glomerulus, podocytes, increases the permeability to proteins, resulting in an
increase in excreted proteins. When the amount of proteins excreted in the urine
exceeds the liver's ability to compensate, fewer proteins are detected in the blood -
in particular albumin, which makes up the majority of circulating proteins. With
decreased proteins in the blood, there is a decrease in the oncotic pressure of the
blood. This results in edema, as the oncotic pressure in tissue remains the same.
This is worsened by the secretion of the hormone Aldosterone by the adrenal
gland, which is secreted in response to the decrease in circulating blood and causes
sodium and water retention. Hyperlipidemia is thought to be a result of the
increased activity of the liver.

Nephritic syndrome

Nephritic syndrome, the nephritic syndrome is characterized by blood in the

urine and a decrease in the amount of urine (oliguria = urine output less than
400-500 ml/24 hours in the presence of hypertension. In this syndrome,
inflammatory damage to cells lining the glomerulus are thought to result in
destruction of the epithelial barrier, leading to blood being found in the urine. At
the same time, reactive changes may result in a decrease in renal perfusion,

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resulting in a decrease in the production of urine. The renin-angiotensin system
may be subsequently activated, because of the decrease in perfusion of
juxtaglomerular apparatus, which may result in hypertension
Signs and symptoms of glomerulonephritis depend on whether you have the
acute or chronic form, and the cause.

Glomerulonephritis signs and symptoms may include:

 Pink or cola-colored urine from red blood cells in your urine (hematuria)

 Foamy urine due to excess protein (proteinuria)

 High blood pressure (hypertension)

 Fluid retention (edema) with swelling evident in your face, hands, feet and
abdomen

 Fatigue from anemia or kidney failure

Investigations:

Some forms of glomerulonephritis are diagnosed clinically, based on findings on

history and examination. Other tests may include:

 Urine examination
 Blood tests investigating the cause, including FBC, inflammatory markers
Antinuclear antibodies
 Biopsy of the kidney

Complications
Complications of glomerulonephritis may include:

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 Acute kidney failure. Loss of function in the filtering part of the nephron may
cause waste products to accumulate rapidly. You may need emergency dialysis —
an artificial means of removing extra fluids and waste from your blood —
typically by an artificial kidney machine.

 Chronic kidney disease. With chronic kidney failure your kidneys gradually lose
their filtering ability. If your kidney function deteriorates to less than 10 percent of
normal capacity, you have end-stage kidney disease, which requires dialysis or a
kidney transplant to sustain life.

 High blood pressure. Damage to your kidneys and the resulting buildup of
wastes in the bloodstream can raise your blood pressure.

 Nephrotic syndrome. With nephrotic syndrome, you have too much protein in
your urine, which results in too little protein in your blood. Nephrotic syndrome
may also be associated with high blood cholesterol and swelling (edema) of the
eyelids, feet and abdomen.

Medical management:

Treatment of glomerulonephritis and your outcome depend on:

 Whether you have an acute or chronic form of the disease

 The underlying cause

 The type and severity of your signs and symptoms

Some cases of acute glomerulonephritis, especially those that follow a strep

infection, tend to improve on their own and often require no specific treatment.

In general, the goal of treatment is to protect your kidneys from further damage.

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Treatment for high blood pressure

Keeping your blood pressure under control is key to protecting your kidneys. To
control your high blood pressure and slow the decline in kidney function, your
doctor may prescribe one of several medications, including:

 Diuretics

 Angiotensin-converting enzyme (ACE) inhibitors

 Angiotensin II receptor blockers

Treatment for an underlying cause

If there's an underlying cause for your kidney inflammation, your doctor may
prescribe other drugs to treat the underlying problem, in addition to treatment to
control any hypertension:

 Strep or other bacterial infection. Treatment usually focuses on easing your

signs and symptoms. Your doctor also may prescribe an appropriate antibiotic.

 Lupus or vasculitis. Doctors often prescribe corticosteroids and immune-

suppressing drugs to control inflammation.

 IgA nephropathy. In some cases, both fish oil supplements and certain
immune-suppressing drugs can successfully treat certain people with IgA
nephropathy. Researchers continue to investigate fish oil supplements for IgA
nephropathy.

 Goodpasture's syndrome. Plasmapheresis is sometimes used to treat people

with Goodpasture's syndrome. Plasmapheresis is a mechanical process that
removes antibodies from your blood by taking some of your plasma out of your
blood and replacing it with other fluid or donated plasma.
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Therapies for associated kidney failure

For acute glomerulonephritis and acute kidney failure, dialysis can help remove
excess fluid and control high blood pressure. The only long-term therapies for end-
stage kidney disease are kidney dialysis and kidney transplant. When a transplant
isn't possible, often because of poor general health, dialysis is the only option.

Lifestyle and home remedies

If you have kidney disease, your doctor may recommend certain lifestyle changes:

 Restrict your salt intake to prevent or minimize fluid retention, swelling and
hypertension

 Cut back on protein and potassium consumption to slow the buildup of wastes
in your blood

 Maintain a healthy weight

 Control your blood sugar level if you have diabetes

 Quit smoking

Prevention
There may be no way to prevent most forms of glomerulonephritis. However, here
are some steps that may be beneficial:

 Seek prompt treatment of a strep infection causing a sore throat or impetigo.

 To prevent infections that can lead to some forms of glomerulonephritis, such

as HIV and hepatitis, follow safe-sex guidelines and avoid intravenous drug
use.

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 Control high blood pressure, which lessens the likelihood of damage to your
kidneys from hypertension.

 Control your blood sugar to help prevent diabetic nephropathy

2. Pyelonephritis

Definition of pyelonephritis:

Pyelonephritis is an inflammation of the kidney parenchyma, calyces, and

pelvis. It is commonly caused by bacterial infection that has spread up the urinary
tract or travelled through the bloodstream to the kidneys. A similar term is
"pyelitis" which means inflammation of the pelvis and calyces.

Classifications:

[Link] pyelonephritis:

Acute pyelonephritis is an exudative purulent localized inflammation of the renal

pelvis (collecting system) and kidney. The renal parenchyma presents in the
interstitium abscesses (suppurative necrosis), consisting in purulent exudate (pus)
neutrophils, fibrin, cell debris and central germ colonies (hematoxylinophils).
Tubules are damaged by exudate and may contain neutrophil casts. In the early
stages, the glomerulus and vessels are normal. Gross pathology often reveals
pathognomonic radiations of bleeding and suppuration through the renal pelvis to
the renal cortex.

2. Chronic pyelonephritis:

Chronic pyelonephritis implies recurrent kidney infections, and can result in

scarring of the renal parenchyma and impaired function, especially in the setting of
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obstruction. A perinephric abscess (infection around the kidney) and/or
pyonephrosis may develop in severe cases of pyelonephritis.

Causes of pyelonephritis:

Most cases of "community-acquired" pyelonephritis are due to bowel organisms

that enter the urinary tract. Common organisms are E. coli (70–80%) and
Enterococcus faecalis. Hospital-acquired infections may be due to coliform
bacteria and enterococci, as well as other organisms uncommon in the community
(e.g., Pseudomonas aeruginosa and various species of Klebsiella). Most cases of
pyelonephritis start off as lower urinary tract infections, mainly cystitis and
prostatitis.[5] E. coli can invade the superficial umbrella cells of the bladder to form
intracellular bacterial communities (IBCs), which can mature into biofilms. These
biofilm-producing E. coli are resistant to antibiotic therapy and immune system
responses, and present a possible explanation for recurrent urinary tract infections,
including pyelonephritis.

Risks and causes of pyelonephritis:

Mechanical: any structural abnormalities in the urinary tract, vesicoureteral reflux

(urine from the bladder flowing back into the ureter), kidney stones, urinary tract
catheterization, ureteral stents or drainage procedures (e.g., nephrostomy),
pregnancy, neurogenic bladder (e.g., due to spinal cord damage, spina bifida or
multiple sclerosis) and prostate disease (e.g., benign prostatic hyperplasia) in men

 Constitutional: diabetes mellitus, immunocompromised states

 Behavioral: change in sexual partner within the last year, spermicide use

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 Positive family history (close family members with frequent urinary tract
infections)

Signs and symptoms:

Symptoms of acute pyelonephritis generally develop rapidly over a few hours or a

day. It can cause high fever, pain on passing urine, and abdominal pain that
radiates along the flank towards the back. There is often associated vomiting.
Chronic pyelonephritis causes persistent flank or abdominal pain, signs of infection
(fever, unintentional weight loss, malaise, decreased appetite), lower urinary tract
symptoms and blood in the urine. Chronic pyelonephritis can in addition cause
fever of unknown origin. Furthermore, inflammation-related proteins can
accumulate in organs and cause the condition amyloidosis. Physical examination
may reveal fever and tenderness at the costovertebral angle on the affected side.

Medical Management:

 In patients suspected of having pyelonephritis, a urine culture and antibiotic

sensitivity test is performed, and initial therapy is tailored on the basis of the
infecting organism.
 As most cases of pyelonephritis are due to bacterial infections, antibiotics are
the mainstay of treatment.
 The choice of antibiotic depends on the species and antibiotic sensitivity profile
of the infecting organism,
 People with acute pyelonephritis that is accompanied by high fever and
leukocytosis are typically admitted to the hospital for intravenous hydration and
intravenous antibiotic treatment.

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 Treatment is typically initiated with an intravenous fluoroquinolone, an
aminoglycoside, an extended-spectrum penicillin or cephalosporin, or a
carbapenem. Combination antibiotic therapy is often used in such situations.
 The treatment regimen is selected based on local resistance data and the
susceptibility profile of the specific infecting organisms.
 During the course of antibiotic treatment, serial white blood cell count and
temperature are closely monitored. Typically, the intravenous antibiotics are
continued until the patient is afebrile for at least 24 to 48 hours, then equivalent
oral antibiotic agents can be given for a total of 2–week duration of treatment.
 Intravenous fluids may be administered to compensate for the reduced oral
intake, insensible losses (due to the raised temperature) and vasodilation and to
optimize urine output.
 Percutaneous nephrostomy or ureteral stent placement may be indicated to
relieve obstruction caused by a stone.

Prevention:

In people who experience recurrent urinary tract infections, additional

investigations may identify an underlying abnormality. Occasionally, surgical
intervention is necessary to reduce the likelihood of recurrence.

If no abnormality is identified, some studies suggest long-term preventive

(prophylactic) treatment with antibiotics, either daily or after sexual activity.

3. Ureteritis
Ureteritis is a medical condition of the ureter that involves inflammation.

One form is known as "ureteritis cystica".

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Eosinophilic ureteritis has been observed.

Ureteritis is often considered part of a urinary tract infection.

II. Lower urinary tract infections

Cystitis

Definition:

Acute cystitis is a bacterial infection of the bladder or lower urinary tract. Acute
means sudden or severe.

Causes of cystitis:

Cystitis is caused by germs, usually bacteria that enter the urethra and then the
bladder. These bacteria can lead to infection, most commonly in the bladder. The
infection can spread to the kidneys.

Most of the time, your body can get rid of these bacteria when you urinate.
However, sometimes the bacteria can stick to the wall of the urethra or bladder, or
grow so fast that some bacteria stay in the bladder.

Women tend to get infections more often than men because their urethra is shorter
and closer to the anus. For this reason, women are more likely to get an infection
after sexual intercourse or when using a diaphragm for birth control. Menopause
also increases the risk for a urinary tract infection.

The following also increase your chances of developing cystitis:

 A tube called a urinary catheter inserted in your bladder

 Blockage of the bladder or urethra
 Diabetes

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  Enlarged prostate, narrowed urethra, or anything that blocks the flow of
urine
 Loss of bowel control (bowel incontinence)
 Older age (especially in people who live in nursing homes)
 Pregnancy
 Problems fully emptying your bladder (urinary retention)
 Procedures that involve the urinary tract
 Staying still (immobile) for a long period of time (for example, when you
are recovering from a hip fracture

Most cases are caused by Escherichia coli (E. coli), a type of bacteria found in the
intestines.

Signs and Symptoms

The symptoms of a bladder infection include:

 Blood in the urine (painless hematuria)

 Cloudy or bloody urine, which may have a foul or strong odor
 Low fever (not everyone will have a fever)
 Pain or burning with urination
 Pressure or cramping in the lower abdomen (usually middle) or back
 Strong need to urinate often, even right after the bladder has been emptied
 Passing frequent, small amounts of urine
 Low-grade fever

Often in an elderly person, mental changes or confusion are the only signs of a
possible urinary tract infection.

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Diagnostic Tests

A urine sample is usually collected to perform the following tests:

 Urinalysis is done to look for white blood cells, red blood cells, bacteria, and
to test for certain chemicals, such as nitrites in the urine. Most of the time,
your health care provider can diagnose an infection using a urinalysis.
 Urine culture - clean catch may be done to identify the bacteria in the urine
to make sure the correct antibiotic is being used for treatment.

Medical management:

Antibiotics taken by mouth are usually recommended because there is a risk that
the infection can spread to the kidneys.

 For a simple bladder infection, you will take antibiotics for 3 days (women)
or 7 - 14 days (men). For a bladder infection with complications such as
pregnancy or diabetes, OR a mild kidney infection, you will usually take
antibiotics for 7 - 14 days.
 It is important that you finish all the antibiotics, even if you feel better.
People who do not finish their antibiotics may develop an infection that is
harder to treat.
 Your health care provider will also want to know if you are pregnant.

 Your health care provider may recommend drugs to relieve the burning pain
and urgent need to urinate.
 You will still need to take antibiotics.
 Everyone with a bladder infection should drink plenty of water.

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  Some women have repeat or recurrent bladder infections. Your health care
provider may suggest several different ways of treating these.

 Taking a single dose of an antibiotic after sexual contact may prevent these
infections, which occur after sexual activity.
 Some women may need to have a 3-day course of antibiotics at home to use
for infections, based on their symptoms.
 Some women may also try taking a single, daily dose of an antibiotic to
prevent infections.

 Over-the-counter products that increase acid in the urine, such as ascorbic

acid or cranberry juice, may be recommended to decrease the concentration
of bacteria in the urine.

 Follow-up may include urine cultures to make sure the bacterial infection is
gone.
 Lifestyle changes may help prevent some urinary tract infections.

Complications:

1. Kidney infection an untreated bladder infection can lead to kidney infection,

also called pyelonephritis
2. Bladder cancer
3. Bladder stone

Treating bacterial cystitis

Antibiotics are the first line of treatment for cystitis caused by bacteria. Which
drugs are used and for how long depend on your overall health and the bacteria
found in your urine.

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 First-time infection. Symptoms often improve significantly within a day or so
of antibiotic treatment. However, you'll likely need to take antibiotics for three
days to a week, depending on the severity of your infection. No matter what the
length of treatment, take the entire course of antibiotics prescribed by your
doctor to ensure that the infection is completely gone.

 Repeat infection. If you have recurrent UTIs, your doctor may recommend
longer antibiotic treatment or refer you to a doctor who specializes in urinary
tract disorders (urologist or nephrologist) for an evaluation, to see if urologic
abnormalities may be causing the infections. For some women, taking a single
dose of an antibiotic after sexual intercourse may be helpful.

 Hospital-acquired infection. Hospital-acquired bladder infections can be a

challenge to treat because bacteria found in hospitals are often resistant to the
common types of antibiotics used to treat community-acquired bladder
infections. For that reason, different types of antibiotics and different treatment
approaches may be needed

Lifestyle and home remedies

Cystitis can be painful, but you can take steps to ease your discomfort:

 Use a heating pad. Sometimes a heating pad placed over your lower abdomen
can help minimize feelings of bladder pressure or pain.

 Stay hydrated. Drink plenty of fluids, but avoid coffee, alcohol, soft drinks
with caffeine, citrus juices and spicy foods until your infection has cleared.
These items can irritate your bladder and aggravate your frequent or urgent
need to urinate.

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 Take a sitz bath. Soaking in a bathtub of warm water (sitz bath) for 15 to 20
minutes may help relieve pain or discomfort.

If you have recurrent bladder infections, let your doctor know. Together, you can
develop a strategy to reduce recurrences and the discomfort that cystitis can bring.

Prevention:

 Drink plenty of liquids, especially water. Drinking lots of fluids is especially

important if you're getting chemotherapy or radiation therapy, particularly on
treatment days.

 Urinate frequently. If you feel the urge to urinate, don't delay using the toilet.

 Wipe from front to back after a bowel movement. This prevents bacteria in
the anal region from spreading to the vagina and urethra.

 Take showers rather than tub baths. If you're susceptible to infections,

showering rather than bathing may help prevent them.

 Gently wash the skin around the vagina and anus. Do this daily, but don't
use harsh soaps or wash too vigorously. The delicate skin around these areas
can become irritated.

 Empty your bladder as soon as possible after intercourse. Drink a full glass
of water to help flush bacteria.

 Avoid using deodorant sprays or feminine products in the genital area.

These products can irritate the urethra and bladder.

3. Urethritis

Urethritis is inflammation of the urethra. That's the tube that carries urine from
the bladder to outside the body. Pain with urination is the main symptom of

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 urethritis. Urethritis is commonly due to infection by bacteria. It can typically be
cured with antibiotics.

Causes

Most episodes of urethritis are caused by infection by bacteria that enter the urethra
from the skin around the urethra's opening. Bacteria that commonly cause urethritis
include:

E. coli and other bacteria present in stool

 Gonococcus, which is sexually transmitted and causes gonorrhea.
 Chlamydia trachomatis, which is sexually transmitted and causes chlamydia.

The herpes simplex virus (HSV-1 and HSV-2) can also cause urethritis.
Trichomonas is another cause of urethritis. It is a single-celled organism that is
sexually transmitted. Sexually transmitted infections like gonorrhea and chlamydia
are usually confined to the urethra. But they may extend into women's reproductive
organs, causing pelvic inflammatory disease (PID).In men, gonorrhea and
chlamydia sometimes cause epididymitis, an infection of the epididymis, a tube on
the outside of the testes. Both PID and epididymitis can lead to infertility.

Signs and symptoms

The main symptom of urethra inflammation from urethritis is pain with urination
(dysuria). In addition to pain, urethritis symptoms include:

 Feeling the frequent or urgent need to urinate

 Difficulty starting urination

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 Urethritis can also cause itching, pain, or discomfort when a person is not
urinating.

Other symptoms of urethritis include:

 Pain during sex

 Discharge from the urethral opening or vagina
 In men, blood in the semen or urine

Diagnosis of Urethritis

You may get a diagnosis of urethritis when your doctor takes your medical history
and asks you about your symptoms.

If you are having painful urination, your doctor may assume an infection is present.
He or she may treat it with antibiotics right away while waiting for test results.

Tests can help confirm the diagnosis of urethritis and its cause. Tests for urethritis
can include:

 Physical examination, including the genitals, abdomen, and rectum

 Urine tests for gonorrhea, chlamydia, or other bacteria
 Examination of any discharge under a microscope

Blood tests are often not necessary for the diagnosis of urethritis. But blood tests
may be done in certain situations.

Nursing care plan for patient with urinary tract infection

1. Pain related to Inflammation & Tissue Trauma as manifested by facial expression of pain

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General Goal: Improve pain levels & relieve associated discomfort by implementing
pharmaceutical interventions to reduce inflammation and pain mediators and pain perception.

2. Electrolyte Imbalance related to Fluid Overload as manifested by Low

Electrolytes (Potassium, Calcium, and Phosphate) & High BUN.

General Goal

Reduce the risk of cardiac complications and other issues by promoting fluids and
electrolyte balance

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