A Study Of Medical-Surgical Nursing

Urinary Tract Infection

In Partial Fulfilment Of The Requirements

In NCM 102

Presented To:

Level-II Clinical Instructor

By:

Casquejo, John Reconell, Rulete, Albert Jon C., Tabaranza, Leovil Joni Jun P.,

Tan, Nolvie A., Vega, Cristine Jane J.

December 14, 2012

TABLE OF CONTENTS

Chapter I - Introduction

Background of the Study...............................................................................01

Objectives.....................................................................................................02

Significance of the Study...............................................................................03

Chapter II – Patient’s Profile (Comprehensive Assessment)

Present Medical History................................................................................04

Past Medical History.........................................................................................

Family History...................................................................................................

Nutritional History..........................................................................................05

Immunization..................................................................................................

Physical Examination..............................................................................06 - 10

1. General Appearance

Chapter III

Pathophysiology........................................................................................11 - 13

Chapter IV – Results, Analysis, And Justification

Course in the Ward............................................................................................

Laboratory Findings.....................................................................................14-17

Drug Study...................................................................................................18 - 21

Nursing Care Plan.......................................................................................22 - 24

Chapter V – Summary, Conclusion, And Recommendation

Bibliography

CHAPTER I

Introduction

Urinary tract infection

Urinary tract infection is an infection involving the kidneys, ureters, bladder, or urethra. Synonyms for UTI include bacteriuritis, asymptomatic bacteriuritis, bacteria cystitis, urethritis, pyelonephritis, and prostatitis. A UTI can cover a wide variety of conditions, ranging from asymptomatic infections with low bacterial counts not requiring intervention to severe infection of the kidney and sepsis with threat to survival. Early intervention has the potential to save costs, prevent significant incapacity, and save lives.

A UTI is labelled according to the region of infection. In general terms, reference is made to lower urinary tract and upper urinary tract infection. In addition, a UTI may be classified by events such as initial or recurrent, acute or chronic. A UTI may be identified as drug-resistant. Combinations of theses labels offer critical information to the provider for assessment, care planning, and patient education purposes. For example, an initial, lower tract UTI most likely prompts a lower level of concern than does a diagnosis of a chronic, recurrent, upper tract UTI.

Further, a UTI may be classified as uncomplicated in patients without structural abnormalities or altered urodynamics or complicated in patients with a structural abnormality or altered urodynamics, or any urinary infection in males.

UTI’s are common during pregnancy because of changes in the urinary tract. The uterus sits directly on top of the bladder. As the uterus grows, it increased weight can block the drainage of urine from the bladder, causing an infection. If the UTI goes untreated, it may lead to kidney infection. Kidney infections may cause early labor and low birth weight. If the doctor will treats a urinary tract infection early and properly , the UTI will not cause harm to the baby.

UTIs prompt over five million office visits annually in the united states. Uncomplicated infections incur annual health care costs in excess of $350

01

million. UTIs are more common in females because of a shorter urethra and the proximity of the urethra to the vagina and anus. Sexual intercourse and forward cleansing following defecation offer primary sources of contamination. Incidence increases in the aging female because of bladder prolapsed. Recurrent infection is common.

In the male, the incidence of bladder infection is higher in the uncircumcised. Incidence in all males increases with age because of problems of prostatic hypertrophy.

Bacteria causing UTI usually originates from the bowel as normal flora of the host. Escherichia coli are the most common infective bacterial organism in acute cystitis and represent 80 present of all cases requiring treatment. E coli bacteria are present in feces, adhere easily to the epithelium of the urinary tract, and have the capability to resist destruction by the white blood cells.

Hospital acquired (nosocomial) infection adds a significant health care dollar burden to the public and to the public and to the institution. UTIs are of particular significance. Physical and psychological stress response to hospitalization predisposes patients to acquired infection. Hospitalized patients frequently require procedure associated bladder catheterization. Catheter intrusion into the urinary system predisposes the patient to inoculation with bacteria contaminated equipment or bacterial entry along the in place catheter. In addition to E. Coli exposure from episodes of fecal incontinence or compromised hygiene, the environment offers exposure to more virulent organisms such as pseudomonas and staphylococcus. More recently, interdisciplinary health faces the challenge of limiting the spread of drug resistant organisms, such as vancomycin resistant enterococcus.

(Contemporay medical-surgical nursing. Thomson asian edition. Rick daniels, laura nosek and leslie nicoll. )

02

OBJECTIVES

General Objectives:

This case study aims to conduct a thorough investigation on urinary tract infection during pregnancy, which aim to provide information and understanding about the underlying cause of the patient’s current condition by the application of the nursing process.

Specific Objectives:

To support the foregoing objective, the following are the specific objectives:

Find a client suited for the case presentation. Get the patients profile (medical history, family background, present

illness, laboratory results) Review concepts and principle related to anatomy and physiology of

affected body organ. Gather all pertinent data from patients chart and assess patient’s history. Make a course in the ward supported by the facts in the doctor’s order. Assess client’s physical status through elaborative physical assessment. Collect and study drugs taken by the patient. Come up with prioritized nursing care plans. Teach client appropriate and relevant life skills that can help her health

status better.

03

Significance of the study

To the client and family:

The study helps to determine the clients condition during her pregnancy

and for her living. It also helps the family to understand the situation or condition

to plan for action in giving appropriate ways in dealing with the client’s needs to

improve and maintain or promote a healthy living.

To the community:

This study will help the community to become aware of the client’s

condition and development. Through this they can address to the client’s needs

in order to solve the problem.

To the students:

Through this study, it will help the students apply their knowledge and

help the client towards a better or healthy condition.

Chapter II – Patient’s Profile (Comprehensive Assessment)

PATIENTS PROFILE

Name: Retes, Florescel Dioso

Age: 29

Sex: Female

Address: P1 B30 L18 Melon street, NHA Bangkal, Davao City

Birthday: September 22, 1983

Birthplace: Midsayap Cotabato

Civil status: Married

Religion: Protestant

Nationality: Filipino

Admission date: Dec. 01, 2012

Admission Time: 01:52 PM

Attending physician: Dr. Regina P. Ingente

Admitting physician: Dr. Gladies Desesto Rioferio, MD

Chief Complaint: Urinary frequency, fever

Diagnosis: Pregnancy uterine 34 4/7 weeks age of gestation, cephalic in preterm labor, to consider urinary tract infection.

Comprehensive assessment

04

Present medical history

Patient has been complaining of pain during urination. Patient also complaining of headache shortly and scaled as 5/10 for 3 weeks. There was no medicine taken and no consultation done. Right prior to admission, patient suffers from urinary frequency associated with fever and uterine contraction were also noted.

Past medical history

The patient verbalized that they don’t have any history of diabetes in their family both on the maternal and paternal side, only hypertension is known. Patient is not known diabetic, hypertensive and asthmatic. She was not hospitalized before, it was her first time to be hospitalized. In her childhood days she only experienced cough and common colds but it was just treated by over the counter medication like paracetamol and carboceistine.

Family medical history

Mrs. R a 29 y.o. housewife and was currently staying with her husband a government employee. She is the youngest among the two siblings. According to the patient they have a history of hypertension in their paternal side and she has no known allergies in any antibiotics and seafood’s. In patient’s heredo familial disease, she said that in their maternal side there is no familial disease.

05

Nutritional Status

The patient stated that Prior to her admission, she ate rice with chicken adobo and a slice of mango for her lunch. Right after her admission, she almost consume the food serving at the hospital and every serving. She love soft drinks right after her meal especially when her pregnancy started. Her husband always bought her burger, fries and orange juice for her snacks. The patient also likes vegetables, fruits, and seafood’s.

Immunization

The patient stated that, during her examination, the Doctor confirmed that she is pregnant. She immediately had her prenatal visit on the month of May 2012, receiving her 1st dose of Tetanus Toxoid. Last June 2012 is her second prenatal visit, receiving her 2nd dose of Tetanus Toxoid, and December is her last visit receiving her 3rd dose of Tetanus Toxoid and The patient is not yet a fully immunized.

06

Physical exam

General appearance

Our client RF, female, 29 years old was admitted to Davao Doctors Hospital on December 01, 2012 at 01:52 pm due to urinary frequency and fever. The assessment was done on Dec. 07, 2012 at Davao Doctors Hospital. Upon assessment the patient was lying on the bed wearing her street clothes with an IVF of D5LR @ 140cc/hr infusing well @ her left metacarpal vein @ 750cc level. She is awake, coherent and responsive and not in any respiratory distress.

VITAL SIGNS AND CLINICAL MEASUREMENT

RESULT NORMAL RANGETemperature 36.2 36.5°C- 37.5°CCardiac rate 89 bpm 80-90 beats/minPulse rate 87 bpm 80-90 beats/minRespiratory rate 22 cpm 16-20 cycles per min.Blood pressure 110/90 mmHg 110/70-130/90 mmHg

07

SKIN

The patient has generally uniform brown complexion. Her skin is smooth, moist and has good skin turgor. The skin of the patient is warm to touch.

Hair and Nails

The patient has smooth, fine shoulder level hair. Her hair is thin and evenly distributed on the scalp. There were no infestation or infections noted. She has clean and trimmed nails. The nail beds are pinkish in color with capillary refill time of 2 seconds.

Skull and Face

The patients head is normocephalic and symmetrical in shape. Her facial features and facial movements are symmetrical. There were no lesions noted.

Eyes

The patient’s eyebrows are black in color and are evenly distributed. They are symmetrically aligned and have coordinated movements. Her lashes are curled outward. The sclera appears white and her irises are black in color. Her pupils are equally round and briskly reactive to light stimulation and accommodation with pupil size of 2 mm. Both eyes move in a coordinated movement.

08

Ears

Patient’s ears are symmetrical and of the same color as her face. The auricles are aligned with the outer canthus of the patient’s eyes. No cerumen was noted upon inspection of the external ear canal and responds to normal voice tones without difficulty. There is no tenderness noted upon palpation.

Nose and Sinuses

The patient’s nose is of the same color as the rest of her face. The nose is symmetric and straight. Upon inspection, the nares were dry and no crusting noted and nasal septum is in midline. There was no tenderness, masses or lesions noted. The maxillary and frontal sinuses are non tender. Signs of inflammation were not noted. No discharges and lesions were noted. The nostrils are patent.

Mouth

The patient’s outer lips are symmetric, moist, pinkish in color and smooth in texture. She is able to move her lips with coordination. Her inner lips and buccal mucosa are pinkish, moist and smooth without lesions. . Her gums are pink in color and moist. There are no retractions noted. The uvula is located at the midline and the tonsils are not inflamed in appearance.

09

Neck

The head is positioned at the center. The neck muscle (sternocleidomastoid and trapezius) appears equal in size and muscle strength is also equal on both sides. The patient displays coordinated and smooth movements with no discomfort. No swelling or masses are noted on the patient’s neck.

The patient’s lymph nodes are non palpable and non-tender. The trachea is at midline. There are no enlargement and masses of the thyroid gland noted.

Chest and Lungs

The skin on the area is clear and same as that of the neck. The clavicles are slightly visible. No masses of sort were noted. The chest wall expands symmetrically and bilaterally.

Breast and Axillae

Rounded shape slightly unequal in size, generally symmetrical.

Abdomen

The abdominal skin is intact and is lighter in color than the extremities. There are no rashes and lesions noted. Her bowel sounds are present. There is no tenderness and enlargement of the liver noted.

10

Genitourinary

The patient refused to do the assessment

Elimination

The patient was not able to defecate during our shift. The patient can void freely. The patient urinated 8x during our shift.

Musculoskeletal

There is an equal size of muscles on both sides of the body with no contractures and tremors. The muscles are firm and moves smoothly and coordinated. There are no deformities of the bones noted.

Chapter III

ANATOMY AND PHYSIOLOGY

The renal system is vital to the functioning of the human body. It is responsible for a wide variety of activities within the body and is integrated with the function of the other body systems. The renal system controls the fluid balance of the body, controls many of the metabolic processes within the body, and provides stabilization for the human body circulation. At the macrovascular level, the renal system consists of two kidneys, ureters, bladder, and urethra.

KIDNEYS

The kidneys are bean-shaped organs, each about the size of a tightly clenched fist. They lie on the posterior abdominal wall, behind the peritoneum, with one kidney on either side of the vertebral column. A connective tissue renal capsule surrounds each kidney. Around the renal capsule is a thick layer of fat, which protects the kidney from mechanical shock. On the medial side of each kidney is the hilum, where the renal artery and nerves enter and where the renal

vein and ureter exit the kidney. The hilum opens into a cavity called the renal sinus, which contains blood vessels, part of the system for collecting urine and fat.

Functions of the kidney:

the primary functions of the kidney are:

1. Maintain fluid and electrolyte balance through excretion and reabsorption.2. Assist in blood pressure regulation through the rennin-angiotensin

system. 3. Maintain chemical balance.4. Maintain mineral balance.5. Produce erythropoietin in response to low oxygen states.6. Convert vitamin D to its active enzyme from and thus influence calcium

metabolism7. Excrete waste products of protein metabolism.8. Contribute to acid base balance.

URETERS,URINARY BLADDER, and URETHRA

The ureters are small tubes that carry urine from the renal pelvis of the kidney to the posterior inferior portion of the urinary bladder. The urinary bladder is a hollow muscular container that lies in the pelvic cavity just posterior to the pubic symphysis. It functions to store urine, and its size depends on the quantity of urine present. The urinary bladder can hold from a few millilitres to a maximum of about 1000 mL of urine. The urethra is a tube that exits the urinary bladder inferiorly and anteriorly. The triangle shaped portion of the urinary bladder located between the opening of the ureters and the opening of the urethra is called the trigone. The urethra carries urine from the urinary bladder to the outer side of the body.

11

14

Urinalysis

Name of pt. : Retes, Florecel Dioso Date: 12/01/12 Physician: Ingente, Regina P

Test name Result Normal Value

Indication Significance

Color

Character

Reaction

Specific Gravity

Albumin

Sugar

Straw

Clear

6 0

1.010

Negative

Negative

Straw(light yellow)

Negative

Negative

A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin. If the sample contained many red blood cells, it would be cloudy as well as red.

Presence of Excess sugar in

The urinalysis is a routine screening test which is usually done as a part of a physical examination, during preoperative testing, and upon hospital admission.

The results of UA are used to diagnose, treat,

and provide follow-up for a

variety of conditions, such as infections of the kidneys and urinary tract and

also in the diagnosis of

diseases unrelated to the urinary system.

WBC

RBC

Epithelialcells

Cast

Bacteria

7ul

9ul

6ul

0ul

698ul

0-17ul

0-11ul

0-17ul

0-1ul

0-278ul

urine means, Glycosuria, generally means diabetes mellitus

Pyuria occurs if the presence of leukocytes are abnormal or increased which may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis

high RBC number in urine may point to acute tubular necrosis, benign familial hematuria, calculi, hemophilia, hemorrhagic cystitis, pyelonephritis, renal trauma, renal tuberculosis, renal tumor, or UTI.

 

Bacteria are common in urine

specimens

because of the abundant normal microbial flora of

the vagina or external urethral

meatus and because of their ability to rapidly multiply in urine standing at room

temperature. Therefore, microbial

organisms found in all but the most

scrupulously collected urines

should be interpreted in view

of clinical symptoms.

15

Complete blood count

Name of pt.: Retes, Florecel Dioso Date: 12/01/12 03:04pmPhysician: Ingente, Regina P

Test name Result Units Normal values

Indication

Significance

Hemoglobin

Hematocrit

128

0.38

g/L 120-140

0.37-0.45

Increased: polycythemia

Decreased: Blood lossHemolytic anemiaSickle cell anemiaBone marrow supression

Increased:PolycythemiaDehydrationBurns

Decreased:Blood lossOverhydr

A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or bruising, a patient may have.

A CBC may be done to:

- Find the cause of symptoms

such as fatigue, weakness, 

Fever, bruising, overweight loss. - Find anemia

- See amount of

Erythrocytes

Leucocytes

Thrombocytes

Segmenters

Lymphocytes

Eosinophils

4.20

5.80

155.0

0.783

0.099

0.001

10^12 /L

10^9/L

10^9/L

H

L

4.5-5.0

5.0-10.0

140-440

0.55-0.65

0.35-0.45

0.02-0.04

ationDietary defeciencyAnemia

Increased:Viral infectionMononucleosisTuberculosisChronic bacterial infections

Decreased:Adrenal corticosteroids and other immunosuppressive drugsSever malnutrition

Increased: allergic reactionsLeukemia

blood loss if there is bleeding.- Diagnose

polycythemia- Find an infection

- Diagnose disease of blood such as leukemia

- Check how body is dealing

with some type of drugs

- Check if abnormal affects the cells inside

- Screen high or low values before

surgery- See if there is an excess or

deficit number of cells that can

indicate conditions

Monocytes

Basophils

MCV

MCH

0.114

0.003

90.10

30.50

L

fL

0.06-0.12

0-0.2

80.97

27.0-31.2

Parasitic infestations

Decreased:Corticosteroid theraphy

Increased:TuberculosisChronic ulcerative colitisProtozoan infections

Decreased: Durg therapy prednisone

Increased:Leukemia

Decreased:Acute allergic reactionCortecosteroidsAcute infections

MCHC 338 pg 318-354

Name of pt.: Retes, Florecel Dioso Date: 12/01/12Physician: Ingente, Regina PExaminatio

nResult Significance

Blood type

RH type

“B”

POS(+)

To prevent RH incompatibility

17

Ave. Ultrasonic age 33W3 D 3 Vessel Cord Y

Ultrasonic EDC 01/18/2013 Bladder Y

Estim. Fetal Weight 2194-4LB13 OZ Distal Fem. Ep.

Gender female

Diagnosis: Pregnancy uterine 33W 3D fetal biometry, Cephalic, Live, Singleton Borderline oligohydramnios AFI= 5.4cm, Anterior placenta grade 2, Female BPS=8/8

Chapter V

Summary, Conclusion and Recommendation

Our pregnant patient is suffering from urinary tract infection, which leads her to different problems, in which somehow it may affect the fetus inside her womb. It affects her daily activities, lifestyle and even her emotional status. It’s not that easy for her to adjust with the environment, because of her situation especially towards her pregnancy. She really wants to have a safe condition in which, she really do her best to have a better outcome or condition. Especially in following the instructions like in taking her prescribed medicines and advises given to her.

We, as a student nurse, we’ve done our part in rendering comfort, management and health teaching, because it’s our responsibility to take good care for our patient. We encourage her to increase her proper hygiene, healthy diet, proper exercise, and emotional management towards a healthy lifestyle not just for her but also for her baby. Increasing proper hygiene is very important to her because of her condition and also on the kind of food that she needs to take for the better. She needs to be conscious on her diet and especially on her wants regarding the food and soft drinks that she always ask for.

Bibliography

Sunner & Suddarth (2007). Medical-Surgical Nursing 7th ed., Lippincott Williams & Wilkins. C & E Publishing., Quezon City Philippines

S.C. Smeltzer et. al., Medical Surgical Nsg. 11th edition

Rick Daniels, Laura Nosek, Leslie Nicoll. Contemporary Medical Surgical Nsg. Thompson Asian edition

http://www.web-books.com/eLibrary/Medicine/Phisiology/Urinary.htm

http://www.scribd.com

kozier and erb’s fundamentals of nursing. 8th edition. Volume one. Berman, synder, kozier erb’s.

Davis’s drug guide for nurses. 11th edition. Judith hopper deglin, pharmD, April hazard vallerand, phd, Rn, FAAN.