pyelonephritis/nephrolithiasis

Question 1

pyelonephritis

Answer 1

kidney infection

Question 2

clinical manifestations of pyelonephritis

Answer 2

mild fatigue to sudden onset of chills, fever, vomiting, flank pain (CVA tenderness)

Question 3

tests for pyelonephritis

Answer 3

UTI diagnosis
WBC with Diff
imaging tests
blood culture –> if suspect bacteremia or urosepsis

Question 4

what would a CDC with diff show if positive for kidney infection

Answer 4

shift to the left = increase N, increase bands (immature)

Question 5

CVA tenderness

Answer 5

costovertebral angle tenderness
-indicative of an upper UTI
-NOT AN EXPECTED FINDING

Question 6

pyelonephritis

Answer 6

inflammation and infection of parenchyma

parenchyma: functional unit of organ
kidneys –> renal cortex and renal medulla

Question 7

care for mild symptoms

Answer 7

outpatient management
-fluids
-NSAIDs/antipyretics (fever-reducer)
-FU urine culture + imagings
-broad ATB, then sensitivity-guided once cultures available (14-21 days)

Question 8

care for severe symptoms

Answer 8

hospitalization
-fluids (IV initially, switch to oral when N/V/dehydration subside)
-NSAIDs/antipyretics
-FU urine culture + images
-IV antibiotics - switch to oral when tolerates intake

Question 9

nephrolithiasis

Answer 9

kidney stone

Question 10

what is indicated when a ureter is obstructed for ANY reason?

Answer 10

nephrostomy tube

Question 11

nephrostomy tube insertion

Answer 11

surgically inserted into renal pelvis through a small flank incision –> external bag for closed drainage of urine

Question 12

urine pathway with nephrostomy tube

Answer 12

urine still made in kidney, but bypasses ureter, bladder and urethra and excretes in bag

Question 13

consideration with nephrostomy tube

Answer 13

if excessive pain or drainage around exit site –> possible blockage

TEMPORARY option

Question 14

nephrostomy tube irrigation

Answer 14

strict aseptic/sterile technique
gently instill no more than 5mL of sterile NS into renal pelvis

*HCP order needed

Question 15

diagnostic studies for nephrolithiasis

Answer 15

-careful H&P
-non-contrast spiral CT GOLD STANDARD
-ultrasound
-intravenous pyelogram (IVP)
-urinalysis (assessing hematuria, crystalluria, pH)
-retrieval/analysis of stones

Question 16

5 major categories of kidney stones

Answer 16

1. calcium oxalate (most common)
2. calcium phosphate
3. uric acid
4. cystine
5. struvite (magnesium ammonium phosphate)

Question 17

symptoms of an acute attack of kidney stones

Answer 17

*pain: flank pain (strongest pain sensations known)
*renal colic: dull, one-sided pain in back or side
*N/V
*infection
*obstruction

Question 18

how to treat pain, infection, obstruction for kidney stones

Answer 18

pain: NSAIDs and opioids

infection: systemic antibiotics

obstruction:
<4mm - pass spontaneously
>4mm - need stent replacement (metal casing that amens ureter and opening or urethra larger)
removal of stones

Question 19

what do you evaluate/prevent and teach patients with kidney stones?

Answer 19

evaluate cause of stone and prevent further development

teach: adequate hydration, how to strain urine

Question 20

dietary changes for pt with kidney stones

Answer 20

low oxalate
low calcium (controversial - stones may not come from calcium)
low purine (if uric acid stone/pt has gout)

Question 21

foods high inn oxalate

Answer 21

WANT TO AVOID THESE IF HAVE KIDNEY STONES

dark roughage*
spinach*
cocoa*
nuts*
asparagus
cabbage
tomatoes
beets
celery
parsley
runner beans
chocolate
instant coffee
tea
Worcestershire sauce

Question 22

foods high in purine

Answer 22

sardines
herring
muscles
liver
kidney
goose
venison
meat soups
sweetbreads

moderate: chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

Question 23

foods high in calcium

Answer 23

Milk
cheese
ice cream
yogurt
sauces containing milk
all beans (except green beans)
lentils
fish (sardines, kippers, herring, salmon)
dried fruits
nuts
Ovaltine
chocolate
cocoa

Question 24

endourologic procedures

Answer 24

lithotripsy - outpatient procedure
disintegrates/pulverizes stones via shock waves

Question 25

internal lithotripsy approach

Answer 25

(direct)
-cystoscopic approach (through urethra to bladder)
-percutaneous approach (through skin)
-laser

Question 26

external lithotripsy approach

Answer 26

(indirect)
-stones broken down and washed out
-non invasive (MAJOR advantage)

complications:
hemorrhage, infection, retention of stone fragments

Question 27

post-procedure lithotripsy

Answer 27

hematuria – expected

stent placed to facilitate passage of fragments – removed after 1-2 weeks

NOT EXPECTED: decrease in urine output; may imply obstruction

Question 28

nursing considerations of kidney stones

Answer 28

goal: pt education - lower risk factors through lifestyle and dietary changes

fluid intake –> water preferred
*3L/day to PREVENT
*NOT to force fluids when MANAGING a stone (no evidence to support it works)

dietary restrictions - determined by type of stone

Question 29

nursing implementation

Answer 29

reduction of risk factors
-sedentary/immobilized person
-adequate fluid intake
-turn q 2 hours
-stand(m)/sit up(f) to pee on regular basis
-encourage ambulation

monitor passing of stones –> filter all urine through gauze or other filter