POST #2 SYDNEY

Pyelonephritis Pyelonephritis is a bacterial infection that occurs in the kidney and renal pelvis (Belyayeva & Jeong, 2020). Pyelonephritis typically occurs from a urinary tract infection that spreads to the kidney. The kidney pelvis becomes filled with purulent exudate, which inflames the medullary tissue. Many times, E. coli is the bacteria that causes pyelonephritis because it has the ability to cling to the urinary tract and colonize (2020). One or both kidneys may be involved in infection. Once the infection from the E. Coli enters the kidney, the purulent exudate starts to form in the renal pelvis.  According to Hubert & Vanmeter (2018), the exudate can create abscesses and necrosis in the medulla of the kidney. It may also reach the cortex and surface of the capsule of the kidney. When the infection is at its worst, the exudate can block the urine flow to the ureter because it compresses on the renal veins and arteries (2018). While pyelonephritis is typically acute, it can be a chronic issue for some patients. Chronic pyelonephritis can lead to loss of tubule function and hydronephrosis; a blockage in the ureter (2018). This can occur because of fibrous scar tissue forming due to chronic or reoccurring infection in the kidney (2018).  There are a few diagnostic tests that diagnose pyelonephritis. The first diagnostic test is a urinalysis that can show white blood cells and microscopic hematuria in the urine (Colgan et al, 2011). It is important for patients that may have pyelonephritis to have a urine culture to find bacteria that cause the infection in the urinary tract (2011). The bladder is a sterile organ; therefore, the presence of bacteria is not a normal finding. Another good diagnostic test to determine pyelonephritis is a CT scan of the kidney. The author states that this shows the structural abnormalities in the kidney. The provider can easily diagnose it and get a better understanding of what parts of the kidney are affected by the pyelonephritis.  When the patient has a diagnosis of pyelonephritis, they need to be started on antibiotics to decrease the infection in the kidney. Antibiotics slow down growth and kill bacteria that is causing the infection. The common antibiotics used to treat pyelonephritis are Bactrim, Keflex and Amoxicillin (Hubert & Vanmeter, 2018). The patient is also encouraged to drink plenty of water, because it can dilute the urine and increase elimination of the bacteria (Belyayeva & Jeong, 2020). The patient is encouraged to follow up in four to six weeks after the initial antibiotic treatment to ensure that the infection is out the urinary tract (2018). Patients may also be encouraged to drink cranberry juice because the tannin in the juice reduces the ability of E. Coli to stay in the mucosa of the bladder (2018).  The prognosis for pyelonephritis is typically good. Many patients heal with oral antibiotics (Belyayeva & Jeong, 2020). This is mostly an outpatient treatment as well. The authors state that there are still some cases of mortality and morbidity when the case of pyelonephritis is severe. There is an increase in mortality if the patient is an elder or already has renal issues because there is a better chance of complication from pyelonephritis to occur. If there is a prompt intervention and treatment is adequate, there are typically good outcomes for patients who have severe pyelonephritis.  In my practice as a WHNP, I feel that this could be an issue that could occur in my female patients. The most common group to get pyelonephritis are sexually active young adult women (2020). The author states that this is because women have a much shorter urethra than men, making it much easier for bacteria to enter the urinary tract. Pregnant women are also at risk for pyelonephritis, as around 20-30% are diagnosed with this during their second trimester (Belyayeva & Jeong, 2020). It is important for women to receive treatment for pyelonephritis as it can cause serious damage and possibly sepsis from the infection in the kidney (2020). Once the patient is diagnosed, my plan of care would include starting an antibiotic for the patients and making sure that they return for a follow up to be sure that the infection is gone. If the patient needs further treatment, I would refer the patient to a urologist who specializes in disorders of the kidney. This would allow for the patient to have the best outcome from pyelonephritis. References Belyayeva, M., & Jeong, J. M. (2020). Acute pyelonephritis. Retrieved from  https://www.ncbi.nlm.nih.gov/books/NBK519537/ Colgan, R., Williams, M., & Johnson, J. R. (2011). Diagnosis and treatment of acute pyelonephritis in women. Retrieved from  https://www.aafp.org/afp/2011/0901/p519.html Hubert, R. J. & VanMeter, K. C. (2018). Gould's pathophysiology for the health professions. St. Louis, MO: Elsevier Saunders.

POST # 1 DANIKA

Topic: Hydronephrosis  The purpose of this initial post is to expand on hydronephrosis. Hydronephrosis occurs when a non-obstructive or obstructive manifestation prevents the normal drainage of urine from the kidneys causing the kidneys to swell and dilate (Nuraj & Hyseni, 2017). The condition most frequently occurs as a secondary complication to obstructions, like renal caculi, strictures or external compression by a tumor, scar tissue, blood clots, and prostatic hypertrophy (Alshoabi, 2018; Nuraj & Hyseni, 2017; VanMeter & Hubert, 2018). Kidney stones are the most common cause of hydronephrosis in young adults and can develop when there are excessive amounts of relatively insoluble salts or insufficient fluid intake leading to high concentrations of urinary filtrate (Iqbal et al., 2017; VanMeter & Hubert, 2018). Older adults develop hydronephrosis from a variety of issues like BPH, carcinoma, retroperitoneal or pelvic neoplasms, neurogenic bladder, bladder neck obstruction, urethral stricture, and bladder stones (Iqbal et al., 2017). Non-obstructive hydronephrosis can occur from excessive fluid intake caused by nephrogenic diabetes insipidus and psychiatric polydipsia. Persistently large volumes of intake can lead to bladder distention and hypertrophy with intramural obstruction of the ureters. When the bladder contractility and ureter peristalsis diminish, a large residual of urine causes urine reflux into the kidneys leading to non-obstructive hydronephrosis (Maroz et al., 2012).   Mild hydronephrosis in pregnancy is a common finding because progesterone causes smooth muscle relaxation and dilation of the renal pelvises and calyceal systems and the expanding uterus compresses the ureters (Mandal et al., 2017). Pregnant women have a 40% increase in development of pyelonephritis due the increased urine volume and stasis. This is significant because pyelonephritis has shown to increase the risk of preterm delivery up to 50% (Mandal et al., 2017). Renal calculi are also common in pregnancy due to increased excretion of uric acid. Hydronephrosis in pregnancy is usually managed conservatively with appropriate hydration and analgesia but may require the insertion of double J stents if severe (Mandal et al., 2017).  The kidneys are constantly creating urine and when the flow is disrupted for an extended amount of time the pressure of the built-up fluid compresses the blood vessels causing necrosis of the renal tissue (VanMeter & Hubert, 2018). The renal impairment from hydronephrosis can cause hypertension, sepsis, urinary infection, hematuria, and ultimately renal failure (Iqbal et al., 2017). The condition may be asymptomatic at first and if allowed to worsen people may experience “flank pain, abdominal mass, nausea and vomiting, urinary tract infection, fever, painful urination (dysuria), increased urinary frequency, and increased urinary urgency” (Nuraj & Hyseni, 2017, p. 159). Hydronephrosis is diagnosed by ultrasound of the kidneys, MRI of the abdomen, a CT of the kidneys or abdomen, or intravenous pyelogram (IVP) Nuraj & Hyseni, 2017. The intravenous pyelogram uses contrast to visualize the structure and abnormalities of the urinary system under X-ray (Radiological Society of North America, 2019). The treatment and prognosis of hydronephrosis is dependent on the underlying cause. Knowledge of the various ways hydronephrosis can develop is essential for APRNs. As an FNP, I will be caring for patients of all ages so a thorough assessment and history of the patient will aid in determining a diagnosis and plan of care. For example, if an older man presents with frequent UTIs, trouble voiding, flank pain, or other urinary symptoms, an ARPN will evaluate for BPH or possibly cancers and assess the risk of the development of hydronephrosis. Young adults experiencing frequent renal calculi will need counseling on how to prevent them in order to reduce the trauma on the urinary tract and prevent hydronephrosis. There are five main types of kidney stones: calcium stones, magnesium ammonium phosphate stones, uric acid stones, cystine stone, and drug induced stones (Alelign & Petros, 2018). If stones can be passed, they should be collected and analyzed to determine the contents of the stone. Vegetarians are more prone to calcium oxalate stones due to high levels of oxalate in the diet (VanMeter & Hubert, 2018). Guaifenesin, triamterene, atazanavir, and sulfa drugs can induce stones so changes in medications may be necessary if drug-induced stones are thought to be the culprit (Alelign & Petros, 2018). Hydronephrosis is a secondary complication so APRNs will first need to find the primary cause to treat it.   References Alelign, T., & Petros, B. (2018). Kidney stone disease: An update on current concepts. Advances in Urology, 2018, 1-12. doi:10.1155/2018/3068365 Alshoabi, S. A. (2018). Association between grades of hydronephrosis & detection of urinary stones by ultrasound imaging. Pakistan Journal of Medical Sciences, 34(4), 955-958. doi:10.12669/pjms.344.14602 Iqbal, S., Raiz, I., & Faiz, I. (2017). Bilateral hydroureteronephrosis with a hypertrophied, trabeculated urinary bladder. Malaysian Journal of Medical Sciences, 24(2), 106-115. doi:10.21315/mjms2017.24.2.14 Mandal, D., Saha, M., & Pal, D. (2017). Urological disorders and pregnancy: An overall experience. Urology Annals, 9(1), 32-36. doi:10.4103/0974-7796.198901 Maroz, N., Maroz, U., Iqbal, S., Aiyer, R., Kambhampati, G., & Ejaz, A. A. (2012). Nonobstructive hydronephrosis due to social polydipsia: A case report. Journal of Medical Case Reports, 6(1), 1-4. doi:10.1186/1752-1947-6-376 Nuraj, P., & Hyseni, N. (2017). The diagnosis of obstructive hydronephrosis with color doppler ultrasound. Acta Informatica Medica, 25(3), 178. doi:10.5455/aim.2017.25.178-181 Radiological Society of North America. (2019). IVP - Intravenous Pyelogram. Retrieved June 23, 2020, from  https://www.radiologyinfo.org/en/info.cfm?pg=ivp