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CASE STUDY: PATIENT WITH URINARY TRACT INFECTION

General Objectives: This case study aims to collect significant information that contributes to the implementation of nursing care to a patient diagnosed with Urinary Tract Infection. Specific Objectives: Conduct a comprehensive interview Assess patient from head to toe Correlate patients laboratory result with his illnesses Administer medications as ordered Provide health education to patient and patients S.Os Implement nursing care plans Implement a discharge plan

DEMOGRAPHIC DATA Name: Sean Alexander Quiban Age: 1 Year & 8 Mos. Address: Brgy. Sta. Cruz, Macrohon SL Birthdate: May 17, 2009 Birthplace: SOYMPH, Maasin City, SL Nationality: Filipino Religion: Roman Catholic Admission: Date: 2/15/11 Time: 11:30 Am Physician: Dr. Malaya Tan

HEALTH HISTORY Chief Complaints Pt. S.A. is a twenty month old bb boy admitted to the hospital due to fever, vomiting, diarrhea and generalized weakness. History of Present Illness According to the pt.s S.O. few days PTA the pt. experienced Diarrhea, low to high grade Fever and Vomiting. The S.O. took the pt. to the manghihilot, administered herbal medications like ilimnon and gave Paracetamol and Metronidazole. She also had the pt. checked over the brgy. Health station but since the pt. looked so weak, she decided to seek medical attention to their Pediatrician.

Past Health History According to the pt.s S.O., this is the first time that the pt. is confined to a health institution since the pt. only experienced minor diseases like fever, cough and colds in the past. Just January of this year, the patient fell into the ground and accidentally hit his head. The pt. was able to consume all of the necessary immunizations which makes him a Fully Immunized Child. No allergies were noted.

Family History of Illness Pt.s S.O. informs that the pt.s paternal side has a history of HPN, DM while on the maternal side, Asthma, HPN and Acute Bronchitis.

GENOGRAM

LEGEND:
HPN
ASTHMA
ACUTE BRONCHITIS

MALE

DM

FEMALE

DEFINITION AND MANAGEMENT OF DISEASE

URINARY TRACT INFECTION


IS A BACTERIAL INFECTION THAT AFFECTS ANY PART OF THE URINARY TRACT. THE MAIN CAUSAL AGENT IS ESCHERICHIA COLI. WHEN BACTERIA GET INTO THE BLADDER OR KIDNEY AND MULTIPLY IN THE URINE, THEY MAY CAUSE A UTI. THE SIGN AND SYMPTOMS OF UTI MAY VARY WITH AGE AND THE PART OF THE URINARY SYSTEM THAT WAS AFFECTED. IN YOUNG CHILDREN, UTI SYMPTOMS MAY INCLUDE DIARRHEA, LOSS APPETITE, NAUSEA AND VOMITING, FEVER. OLDER CHILDREN ON THE OTHER HAND MAY EXPERIENCE ABDOMINAL PAIN OR INCONTINENCE. LOWER UTI IN ADULTS MAY MANIFEST HEMATURIA, INABILITY TO URINATE DESPITE THE URGE AND MALAISE. OTHER SIGNS OF UTI INCLUDE FOUL-SMELLING URINE THAT APPEARS CLOUDY. RISK FACTORS INCLUDE INTERCOURSE, SEX,URINARY CATHETERS, GENETICS and OTHERS

DIAGNOSIS AND TREATMENT


The diagnosis of UTI is usually based on symptoms and on examination of the urine for the presence of microorganisms. When necessary, x-ray films, ultrasonography and ct and renal scans are used to identify contributing factors, such as obstruction. treatment of UTI is based on the type of infection that is present ( lower or upper UTI ), the pathogen causing the infection and the presence of contributing host agent factors. Other considerations include whether the infection is acute, recurrent or chronic.

Acute Lower UTI


Treated successfully with a short course of antimicrobial therapy. Forcing fluids may relieve signs and symptoms, and this approach is used as an adjunct to antimicrobial treatment.

RECURRENT LOWER UTI


-are those that return after treatment.

CRANBERRY JUICE OR BLACKBERRRY JUICE HAS BEEN SUGGESTED AS A PREVENTIVE MEASURE FOR PERSONS WITH FREQUENT UTI. USED APPROPRIATELY IN PREVENTION RATHER THAN TREATMENT OF AN ESTABLISHED UTI.

CHRONIC UTIs ARE ASSOCIATED


WITH OBSTRUCTIVE UROPATHY or REFLUX FLOW OF URINE, DIAGNOSTIC TESTS USUALLY ARE PERFORMED TO DETECT SUCH ABNORMALITIES ANTIBIOTIC THERAPY 10 to 14 DAYS IN DOSES SUFFICIENT TO MAINTAIN HIGH URINE LEVELS OF THE DRUG AND THEY ARE EXAMINED FOR OBSTRUCTION OR OTHER CAUSES OF INFECTION.

ANATOMY AND PHYSIOLOGY

The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside.

PHYSICAL EXAMINATION

PHYSICAL ASSESSMENT General Appearance: Patient S.A. is conscious and coherent, has fair complexion, with IV on his right arm D5 IMB @ 60 gtts/min. The patient has diapers. Skull and face skull are symmetrical round, hard and smooth without lesions. face are symmetric, no abrasions were noted. Hair colored black and evenly distributed short, straight hair free from infestation of lice smooth and firm Eyes

Eyes round eyes short eyelashes eyeballs are symmetrically aligned in sockets without protruding or sinking conjunctiva are pink, no lesions and discharge transparent conjunctiva and lens white sclera iris is typically round, flat and evenly colored pupils equally round, reactive to light accommodation Ears equal in size bilaterally consistent with facial color symmetrical with upper attachment free from lesions and pain ear wax discharge is present able to hear words

Nose and Sinuses frontal and maxillary sinuses are non tender color is the same as the rest of the face no inflammation of sinuses upon palpation no mucous discharge external pinnae are symmetrical and non-tende Mouth lips are acyanotic and free from lesions Mucosa are pinkish Mouth is able to open widely Skin fair and smooth to touch without lesions temperature is 37 C Nails clean nails noted ,nail bed is acyanotic nail base is firm 180-degree angle between the nail base and the skin

Neck able to move without complaint of pain symmetric without bulging masses muscles are symmetrical with head lymph nodes are palpable trachea in the midline Thorax and Lungs posterior and anterior thorax is free from lesions breathing pattern is regular respiration is 50 cpm symmetric chest slope of the ribs is symmetrical spine is straight scapula are symmetric breath sounds are vesicular

Cardiovascular system heart rate is 130 bpm S1 and S2 are audible absence of visible pulsations pulses are equal in rate and rhythm Abdomen rounded abdomen 10 inches waistline circumference non tender and soft bowel sounds are loud without lesions External Genitalia, Anus and Rectum The penis does not have discharge scrotum equal in shape L lower than R no nodules and lesions noted

Musculoskeletal System posture erect, moves all time hands and fingers are symmetric, no tenderness and lesions noted feet are in alignment with lower legs lower leg in alignment with upper leg toes and feet are in alignment with the lower leg Neurologic conscious good eye contact able to hear able to swallow follows directions accurately her eyes are in coordinated motion in all directions

GORDONS FUNCTIONAL HEALTH PATTERN

GORDONS FUNCTIONAL HEALTH PATTERN


HEALTH PERCEPTION- HEALTH MANAGEMENT According to his S.O. pt. S.A. health for her bb is the most important aspect of their life. She would rely on alternative medications like herbs when her bb gets sick. During hospitalization the pt.s health status is improving. NUTRITIONAL METABOLIC PATTERN The mother of the pt. informs that she stopped giving breast milk to the pt. when the pt. is already 9 months old. She started complimentary feeding when the pt. reached 5 months old. During hospitalization, the pt. started to show poorness of appetite but during the second day in the hospital, the mother informs that the pt. already gains good eating habits. ELIMINATION PATTERN The pt. usually defecates in the morning. During hospitalization, the pt. defecates 3 5 times. The S.O. changes the diaper 4 5 times in a day. ACTIVITY-EXERCISE PATTERN Pt.s S.O. states that the pt. is very playful and active. During hospitalization, the pt. is less energetic and playful.

SLEEP- REST PATERN Pt.s sleeping pattern includes 8 hour of sleep in the evening and 2 to 3 hour sleep in the morning. The pt. usually has two pillows and drinks bottled milk before getting a nap. During hospitalization, the pt. no loner achieves the 8 hour sleep in a day due to the pain and changes in room temperature. COGNITIVE-PERCEPTUAL PATTERN Pt.s S.O. states that the pt. is a fast learner and can easily grasp whatever she teaches to the pt. during hospitalization, the pt. listens and is able to follow instructions. ROLE-RELATIONSHIP PATTERN Pt. S.A. is the only child, he lives with his mother and grandmother. During hospitalization, the pt. has his mother on his bedside. SEXUALITY REPRODUCTIVE PATTERN Patient has not yet been circumcised yet. COPING STRESS TOLERANCE PATTERN According to the pt.s S.O. the things that can easily remove the tantrums of the pt. are toys and bottled milk. She also sings the lullabye and dances while carrying the pt. During hospitalization, the pt. plays with the toys and cellphone. VALUE BELIEF PATTERN Pt.s S.O. states the pt. is a Roman Catholic.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Loss of integrity of the mucosal lining (caused by in indwelling catheter, tumor, parasites, or calculus) Decreased resistance to invading organisms Inflammatory changes occur in the affected portion of the Urinary tract.
Etiology: Causative organism: -Escherichia Coli 90% of UTI in women. -Enterocobacter -- Pseudomonas -- Serratia -- Staphylococcus saprophyticus -- Candida

Clumps of bacteria may be present

Inflammatory changes in the renal pelvis and throughout the kidney.

Scarring of the kidney parenchyma (occurs in chronic infection), which interferes kidney function.

LABORATORY EXAMS

LABORATORY EXAM

NORMAL FINDINGS

PATIENTS RESULTS

SIGNIFICANCE

HEMATOLOGY

The science dealing with the formation, composition, functions and diseases of the morphology of the blood forming organs

* Leukocyte # cone : 4.5 11.0 x 109 / L * Thrombocytes # cone : 150 - 400 x 109 / L * Hemoglobin Mass cone : 139 - 163 g / L * Different Counts Segmenters : 0.31 - 0.76 % Lymphocytes : 0.14 - 0.44 % Eosinophils : 0 - 0.04 % * Erythrocyte vol. fraction : 0.40 0.52 x 1011 /L

LEUCOCYTES# CONC: 9.6 x 109/L THROMBOCYTE# CONC: 264.0 x 109/L


HEMOGLOBIN MASS CONC:

N.R. g/dl

LABORATORY EXAM

NORMAL FINDINGS COLOR: PALE YELLOW APPEARANCE: CLEAR Ph: 4.6 8.0 Sp. GRAVITY: 1.003 1.030 PROTEIN:0 KETONES:0 GLUCOSE:0 WBC: <5% per HIGH POWER FIELD

PATIENTS RESULTS COLOR: YELLOW ALBUMIN: NEGATIVE SUGAR: NEGATIVE CHARACTER: Sl. CLOUDY REACTION (PH): 6.0 Sp. GRAVITY 1.025

SIGNIFICANCE
*COLOR IS INFUENCED BY URINE CONCENTRATION AND INGREDIENTS AND IF FRESH BLOOD IS PRESENT, URINE MAY BE RED; IF OLD BLOOD, IT MAY BE BROWN OR BLACK. *BACTERIA, EXCESSIVE CRYSTALS OR CELLS CAUSE CLOUDINESS; IF PROTEIN CONTENT IS HIGH, IT FOAMS LIKE BEER WHEN IT IS POURED. *URINE BECOMES ALKALINE ( Ph MORE THAN 7) W/ UTI OR SEVERE ALKALOSIS; *Sp. GRAVITY IS ELEVATED IN DEHYDRATION AS KIDNEYS TRY TO CONSERVE FLUID, AND DECREASED IN OVERHYDRATONAS THEY TRY TO RID THE BODY FLUID. *GLUCOSE IN URINE OCCURS MOST FREQUENTLY AS A SYMPTOM OF DM *WBC ARE ROUND, SMALL CONFIGURATIONS ON A MICROSCOPIC SLIDE, THEY ARE PRESENTWITH BACTERIURIA. *CRYSTAL FORMATION IS POSSIBLY INDICATION OF URINE PH; URIC ACID, CYSTINE AND CALCIUM OXALATE

URINALYSIS

WBC/HPF: 4.6
EPITH. CELLS: FEW CALCIUM OXALATES: PLENTY

BACTERIA: FEW

LABORATORY EXAM NORMAL FINDINGS

PATIENTS RESULTS

SIGNIFICANCE

STOOL EXAMINATION

PHYSICAL CHARACTER: FORMED COLOR: YELLOWISH GREEN BACTERIA: PLENTY

DRUG SUMMARY

GENERIC NAME
BRAND NAME DRUG CLASSIFICATION

Albuterol Salbutamol
Bronchodilator (therapeutic); adrenergics (pharmacologic)

MECHANISM OF ACTION

It relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. The relief from nasal congestion and bronchospasm is made possible by the following mechanism that takes place when Salbutamol is administered. First, it binds to the beta2-adrenergic receptors in the airway of the smooth muscle which then leads to the activation of the adenyl cyclase and increased levels of cyclic- 35-adenosine monophosphate (cAMP). When cAMP increases, kinases are activated. Kinases inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased in intracellular calcium will result to the relaxation of the smooth muscle airways.

INDICATION

To control and prevent reversible airway obstruction caused by asthma or chronic obstructive pulmonary disorder (COPD) Quick relief for bronchospasm For the prevention of exercise-induced bronchospasm Long-term control agent for patients with chronic or persistent bronchospasm

SIDE EFFECTS

Nervousness, Restlessness Tremor, Headache ,Insomnia, Chest pain Palpitations, Angina ,Arrhythmias, Hypertension Nausea and vomiting ,Hyperglycemia, Hypokalemia
Assess lung sounds, PR and BP before drug administration and during peak of medication. Observe fore paradoxical spasm and withhold medication and notify physician if condition occurs. Administer PO medications with meals to minimize gastric irritation. Extended-release tablet should be swallowed-whole. It should not be crushed or chewed. If administering medication through inhalation, allow at least 1 minute between inhalation of aerosol medication. Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth. Inform the patient that Albuterol may cause an unusual or bad taste.

NURSING
INTERVENTIONS

GENERIC NAME
BRAND NAME
DRUG CLASSIFICATION MECHANISM OF ACTION

cefuroxime
Ceftin second-generation cephalosporin antibiotic Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death. Oral (Cefuroxime Axetil) Pharyngitis, tonsilitis caused by S. pyogenes Otitis media caused by S. pneumoniae, H. influenzae, M. catarrhalis, S. pyogenes Lower respiratory tract infections caused by S. pneumoniae, H. parainfluenxae, H. influenzae UTIs caused by E. coli, K. pneumoniae Dermatologic infections, including impetigo caused by S. aureus, S. pyogenes

INDICATION

SIDE EFFECTS

generally well tolerated side effects are usually transient. effects of diarrhea, nausea, vomiting, headaches/migraines, dizziness and abdominal pain.
Cefuroxime axetil for PO use is available in tablet and suspension forms. Swallow tablets whole and not crush, crushed tablet has a strong, bitter, persistent taste. The tablets may be taken without regard for food. Protect tablets from excessive moisture. 2. Tablet are not bio-equivalent and not substitutable on a mgper-mg basis. 3. Prior to reconstitution, protect drug from light. The power and reconstituted drug may darken without affecting potency. 4. Continue therapy for at least 10 days in infections due to Streptococcus pyogenes. 5. Do not take cefuroxime if patient have ever had an allergic reaction to another cephalosporin or to a penicillin unless the doctor is aware of the allergy and monitors their therapy.

NURSING INTERVENTION

NURSING CARE PLANS

ASSESSMENT
SUBJECTIVE OBJECTIVE

sakit ijang pag.ihi day as verbalized by the S.O.

Facial grimace. Restlessness. V/S taken as follows: T 36.3 P: 82 R: 26

DIAGNOSIS
Acute pain related to biological factors such as trauma or activity of disease process

PLANNING
After 2-3 hours of nursing interventions, the patients pain will be relieved or controlled.

IMPLEMENTATION with RATIONALE


Independent: Assess pain, noting location, intensity (scale of0 10), duration. Provides information to aid in determining choice or effectiveness of interventions.

Encourageincreased fluid intake. Investigate report of bladderfullness.


Observe for changes in mental status, behavior or level of consciousness. Provide comfort measure like back rub, helping patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercises. Encourage use ofsitz baths, warm soaks to the perineum . Collaborative:Administer antibacterial as prescribed.

Increased hydration flushes bacteria and toxins.

Promotes relaxation, refocuses attention, and may enhance coping abilities.

ASSESMENT
SUBJECTIVE OBJECTIVE

DIAGNOSIS Deficient knowledge r/t emotional state affecting learning (anxiety, denial, or depression) INFERENCE Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). The nurse must decide with the learner what to teach, when to teach, and how to teach the mutually agreed-on content. Adult learning principles guide the teaching-learning process.

PLANNING After 2-3 hours of nursing interventions the patients SO verbalizes understanding of desired content, and/or performs desired skill. IMPLEMENTATION with RATIONALE Provide physical comfort for the learner. This allows patient to concentrate on what is being discussed or demonstrated. According to Maslows theory, basic physiological needs must be addressed before patient education. This allows patient to concentrate more completely. This is especially important when providing education to patients with different values and beliefs about health and illness.

Provide a quiet atmosphere without interruption. Provide an atmosphere of respect, openness, trust, and collaboration.

Establish objectives and goals for learning at This allows learner to know what will be the beginning of the session. discussed and expected during the session. Adults tend to focus on here-and-now, problem-centered education.

Allow learner to identify what is most important to him or her. Explore attitudes and feelings about changes.

This clarifies learner expectations and helps the nurse match the information to be presented to the individuals needs. This assists the nurse in understanding how learner may respond to the information and possibly how successful the patient may be with the expected changes.

Allow for and support self-directed, selfdesigned learning.

Adults learn when they feel they are personally involved in the learning process. Patients know what difficulties will be encountered in their own environments, and must be encouraged to approach learning activities from their priority needs.
This helps learner make adjustments in daily life that will result in the desired change in behavior (or learning). Information that is in direct conflict with what is already held to be true forces a reevaluation of the old material and is thus integrated more slowly.

Assist the learner in integrating information into daily life. Allow adequate time for integration that is in direct conflict with existing values or beliefs.

ASSESSMENT SUBJECTIVE DIAGNOSIS OBJECTIVE

Disturbed Thought Processes - Altered Sleep r/t Sleep deprivation


PLANNING After 6 hours of nursing intervention the Patient achieves normal sleep pattern.

INTERVENTIONS with RATIONALE


Decrease stimuli before patient goes to bed by suggesting a warm bath, turning down television or radio, and dimming the lights Decrease intake of caffeinated substances (e.g., tea, colas, coffee Sleep and rest will be encouraged when loud stimuli are minimized. Caffeine stimulates CNS and may interfere with patients ability to rest and sleep.

Evaluate sedative effects of medications and This discourages sleeping during day and schedule administration to diminish daytime promotes restful night sleep. sedation and promote sleep at night.

IF patient is experiencing hypersomnia, discourage sleep during the day. Limit the time patient spends in his or her room and provide stimulating activities.

Structured expectations provide a focus for activities, and contact also provides opportunity to examine feelings the patient may be avoiding through excessive sleep. ARRANGED SLEEPING ACCESSORIES INITIATES SOUND SLEEP. COMFORT IS A GREAT FACTOR IN HAVING SOUND SLEEP

ARRANGE PILLOWS AND LINENS PROVIDE PT. WITH COMFORT

ASSESSMENT SUBJECTIVE OBJECTIVE DIAGNOSIS Health-Seeking Behaviors r/t Lack of knowledge about health promotion behaviors PLANNING After 2-3 hours of nursing intervention the Patient identifies necessary environmental changes to promote a healthier lifestyle. INTERVENTIONS with RATIONALE Clearly define the specific behavior to be changed. Guide the patient in setting realistic goals. Promote positive expectations for success. The more precisely defined the behavior is, the greater the chance of success. Goals that are too global are difficult to achieve and can foster feelings of failure Patients with stronger self-efficacy to perform a behavior are much more likely to engage in it.

Assist patient in developing a self-contract

Contracts help to clarify the goal and enhance the patients control over the behavior, creating a sense of independence, competence, and autonomy.

Assist in developing a time frame for implementation.

Changes need to be made over a period to allow new behaviors to be learned well, integrated into ones lifestyle, and stabilized.
This provides a systematic approach for movement of patient toward higher levels of health and promotes adherence to plan. Appropriately timed feedback is critical to successful behavior change. Observing the behavior of others who have successfully achieved similar goals helps exemplify the exact behaviors that should be developed to reach the goal. The use of videotapes with people performing the desired behavior has been quite effective.

Allow periodic evaluation, feedback, and revision of health plan as necessary.

Implement the use of modeling to assist patients.

Discharge Plan
Name: SEAN ALEXANDER QUIBAN Age: 20 mos. Sex: M Religion: ROMAN CATHOLIC Diagnosis: URINARY TRACT INFECTION Surgery Undergone, if any: NONE Hospital: SOYMPH Rm./Ward: MALNUTRITION ROOM PEDIATRIC WARD Physician: DR. MALAYA TAN OBJECTIVES: * continuation of nursing care in home setting * implementation of necessary nursing measures at home *application of therapeutic and non-pharmacological ways at the onset of UTI *health maintenance and health promotion Exercise / Activity: NA Type of Activity Allowed / to be continued: NA Procedure or Steps: NA Use of Equipment (if any): NA

SAINT JOSEPH COLLEGE PRACTICAL NURSING DEPARTMENT NCM 102 GROUP 2

ZEDRICK G. MALBAS ROSEMIE LOPEZ ANDRO EARL COMPENDIO JOMAVIR ACOMPANDO RHEA DAGDAG IRIS TABAYAG MA. MAE KAINDOY

RITCH PATRICK GO CLINICAL INSTRUCTOR