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 interviewAssess patient from head to toeCorrelate patient’s laboratory result with his illnessesAdminister medications as orderedProvide health education to patient and patient’s S.OsImplement nursing care plansImplement a discharge plan

DEMOGRAPHIC DATA

Name: Sean Alexander Quiban Age: 1 Year & 8 Mos.Address: Brgy. Sta. Cruz, Macrohon SLBirthdate: May 17, 2009Birthplace: SOYMPH, Maasin City, SLNationality: FilipinoReligion: Roman CatholicAdmission: Date: 2/15/11 Time: 11:30 AmPhysician: 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 IllnessAccording 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 HistoryAccording 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 IllnessPt.’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 MALE

DM ACUTE BRONCHITIS 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 UTI’s ARE ASSOCIATEDWITH 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 faceskull are symmetrical round, hard and smooth without lesions.face are symmetric, no abrasions were noted.

• Haircolored black and evenly distributedshort, straight hairfree from infestation of licesmooth and firmEyes

• Eyesround eyes short eyelasheseyeballs are symmetrically aligned in sockets without protruding or sinkingconjunctiva are pink, no lesions and discharge transparent conjunctiva and lenswhite sclerairis is typically round, flat and evenly colored pupils equally round, reactive to light accommodation

• Earsequal in size bilaterallyconsistent with facial colorsymmetrical with upper attachment free from lesions and painear wax discharge is presentable to hear words

• Nose and Sinusesfrontal and maxillary sinuses are non tendercolor is the same as the rest of the faceno inflammation of sinuses upon palpationno mucous dischargeexternal pinnae are symmetrical and non-tende

• Mouth

lips are acyanotic and free from lesionsMucosa are pinkish

Mouth is able to open widely• Skin

fair and smooth to touchwithout lesionstemperature is 37 °C

• Nailsclean nails noted ,nail bed is acyanoticnail base is firm180-degree angle between the nail base and the skin

• Neckable to move without complaint of painsymmetric without bulging massesmuscles are symmetrical with headlymph nodes are palpabletrachea in the midline

• Thorax and Lungs

posterior and anterior thorax is free from lesionsbreathing pattern is regularrespiration is 50 cpm symmetric chestslope of the ribs is symmetricalspine is straight scapula are symmetricbreath sounds are vesicular

• Cardiovascular systemheart rate is 130 bpmS1 and S2 are audibleabsence of visible pulsationspulses are equal in rate and rhythm

• Abdomenrounded abdomen10 inches waistline circumferencenon tender and softbowel sounds are loudwithout lesions

• External Genitalia, Anus and RectumThe penis does not have dischargescrotum equal in shape L lower than Rno nodules and lesions noted

• Musculoskeletal Systemposture erect, moves all timehands and fingers are symmetric, no tenderness and lesions notedfeet are in alignment with lower legslower leg in alignment with upper legtoes and feet are in alignment with the lower leg

• Neurologicconsciousgood eye contact able to hearable to swallow

follows directions accuratelyher eyes are in coordinated motion in all directions

GORDON’S FUNCTIONAL HEALTH PATTERN

GORDON’S 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 PATTERNThe 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 PATTERNThe 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 PATTERNPt.’s S.O. states that the pt. is very playful and active. During hospitalization, the pt. is less energetic and playful.

• SLEEP- REST PATERNPt.’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 PATTERNPt.’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 PATTERNPt. 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 PATTERNPatient has not yet been circumcised yet.

• COPING – STRESS TOLERANCE PATTERNAccording 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 PATTERNPt.’s S.O. states the pt. is a Roman Catholic.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGYLoss 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.

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.

Etiology: Causative organism: -Escherichia Coli – 90% of UTI in women. -Enterocobacter -- Pseudomonas -- Serratia -- Staphylococcus saprophyticus -- Candida

LABORATORY EXAMS

LABORATORY EXAM NORMAL FINDINGS PATIENT’S 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 PATIENT’S RESULTS SIGNIFICANCE

URINALYSIS 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

COLOR: YELLOW

ALBUMIN: NEGATIVE

SUGAR: NEGATIVE

CHARACTER: Sl. CLOUDY

REACTION (PH): 6.0

Sp. GRAVITY 1.025

WBC/HPF: 4.6

EPITH. CELLS: FEW

CALCIUM OXALATES: PLENTY

BACTERIA: FEW

*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

LABORATORY EXAM

NORMAL FINDINGS PATIENT’S RESULTS SIGNIFICANCE

STOOL EXAMINATION

PHYSICAL CHARACTER: FORMED

COLOR: YELLOWISH GREEN

BACTERIA: PLENTY

DRUG SUMMARY

GENERIC NAME Albuterol

BRAND NAME Salbutamol

DRUG CLASSIFICATION 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- 3’5’-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

NURSING INTERVENTIONS

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.

GENERIC NAME cefuroxime

BRAND NAME Ceftin

DRUG CLASSIFICATION second-generation cephalosporin antibiotic

MECHANISM OF ACTION Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death.

INDICATION 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

SIDE EFFECTS generally well tolerated side effects are usually transient. effects of diarrhea, nausea, vomiting, headaches/migraines, dizziness and abdominal pain.

NURSING INTERVENTION

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 mg-per-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 CARE PLANS

ASSESSMENTSUBJECTIVE 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

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

PLANNINGAfter 2-3 hours of nursing interventions, the patient’s pain will be relieved or controlled.

IMPLEMENTATION with RATIONALEIndependent:•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.

Increased hydration flushes bacteria and toxins.

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

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

. Collaborative:Administer antibacterial as prescribed.

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 patient’s 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 Maslow’s theory, basic physiological needs must be addressed before patient education.

Provide a quiet atmosphere without interruption.

This allows patient to concentrate more completely.

Provide an atmosphere of respect, openness, trust, and collaboration.

This is especially important when providing education to patients with different values and beliefs about health and illness.

Establish objectives and goals for learning at the beginning of the session.

This allows learner to know what will be 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.

This clarifies learner expectations and helps the nurse match the information to be presented to the individual’s needs.

Explore attitudes and feelings about changes.

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, self-designed 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.

Assist the learner in integrating information into daily life.

This helps learner make adjustments in daily life that will result in the desired change in behavior (or learning).

Allow adequate time for integration that is in direct conflict with existing values or beliefs.

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.

ASSESSMENT

SUBJECTIVE OBJECTIVE

DIAGNOSIS

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

Sleep and rest will be encouraged when loud stimuli are minimized.

Decrease intake of caffeinated substances (e.g., tea, colas, coffee

Caffeine stimulates CNS and may interfere with patient’s ability to rest and sleep.

Evaluate sedative effects of medications and schedule administration to diminish daytime sedation and promote sleep at night.

This discourages sleeping during day and promotes restful night sleep.

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.

ARRANGE PILLOWS AND LINENS ARRANGED SLEEPING ACCESSORIES INITIATES SOUND SLEEP.

PROVIDE PT. WITH COMFORT COMFORT IS A GREAT FACTOR IN HAVING SOUND SLEEP

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.

The more precisely defined the behavior is, the greater the chance of success.

Guide the patient in setting realistic goals. Goals that are too global are difficult to achieve and can foster feelings of failure

Promote positive expectations for success. 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 patient’s 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 one’s lifestyle, and stabilized.

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

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.

Implement the use of modeling to assist patients.

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.

• Discharge Plan

Name: SEAN ALEXANDER QUIBAN Age: 20 mos. Sex: M Religion: ROMAN CATHOLICDiagnosis: URINARY TRACT INFECTION Surgery Undergone, if any: NONEHospital: SOYMPH Rm./Ward: MALNUTRITION ROOM – PEDIATRIC WARDPhysician: 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: NAType of Activity Allowed / to be continued: NAProcedure or Steps: NAUse 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