Urinary Tract Infection Case Study

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    A Case Study:

    UrinaryTract

    Infection

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    INTRODUCTION

    A Urinary Tract Infection (also called a UTI for short) is an infection of the body's system

    involved in excreting urine. This can take place in the kidneys, the ureter the bladder or the

    urethra. Most often this occurs in the urethra and bladder. Studies are inconclusive on this

    point. Some doctors theorize that as the uterus grows its increased weight can block the drainage

    of urine from the bladder, causing an infection.

    Urinary tract infections (UTIs) are one of the most common bacterial infections during

    pregnancy. UTIs are associated with risks to both the fetus and the mother, including

    pyelonephritis, preterm birth, low birth weight, and increased perinatal mortality. The prevalence

    rates of bacteriuria in pregnant women and nonpregnant women are essentially the same. UTIs

    are more common in women when compared with men, primarily because of the anatomic

    differences of the shorter urethra and its proximity to the vagina and the rectum. However, when

    pregnant women have a urinary tract infection, they have a higher risk for and increased

    occurrence of upper tract UTIs when compared with lower tract UTIs.

    Several physiologic changes occur during pregnancy that cause otherwise healthy women to be

    more susceptible to serious sequelae from urinary tract infections.The infections can be

    symptomatic or asymptomatic. Asymptomatic bacteriuria, as the name implies, is a positive

    urine culture without specific symptoms. Asymptomatic bacteriuria increases the risk for an

    upper tract UTI, also known as pyelonephritis. Treatment of asymptomatic bacteriuria reduces

    the risk of a symptomatic infection.

    The frequency of asymptomatic bacteriuria occurs in 2-7% of pregnancies, similar to the

    nonpregnant population. However, up to 40% of these may progress to symptomatic upper tract

    UTI or pyelonephritis, significantly more than in nonpregnant women.4

    Several factors are

    associated with an increased frequency in various patient populations. Indigent patients have a 5-

    fold increased incidence of bacteriuria compared with that of nonindigent patients. The risk is

    doubled in women with sickle cell trait. Other risk factors for bacteriuria include diabetes

    mellitus, neurogenic bladder retention, and a history of previous urinary tract infections.

    http://emedicine.medscape.com/article/245559-overviewhttp://emedicine.medscape.com/article/127547-overviewhttp://emedicine.medscape.com/article/127547-overviewhttp://emedicine.medscape.com/article/453539-overviewhttp://emedicine.medscape.com/article/453539-overviewhttp://emedicine.medscape.com/article/127547-overviewhttp://emedicine.medscape.com/article/127547-overviewhttp://emedicine.medscape.com/article/245559-overview
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    PATIENTS PROFILE

    Name : Mrs. UTI

    Age : 28 years old

    Sex : Female

    Civil Status : Married

    Nationality : Filipino

    Address : Cabilang Baybay, Carmona, Cavite

    Occupation : Housewife

    Birthday : May 22, 1982

    Birthplace : Carmona, Cavite

    Date of Admission : 10:36 am, August31, 2010

    Admitting Physician : Dr. Salayog, Benjamin Jorge

    Attending Physician : Dr. Elefante-Delacruz, Vilma

    Admission Diagnosis : PU 34 3/7 weeks AOG by LMP G2P1 T/C UTI

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    PAST MEDICAL HISTORY

    It was hersecond hospitalization in Binan Doctors Hospital after she delivered her 1st

    child via

    normal spontaneous vaginal delivery last November 7, 2007. She has no known cause of

    allergies, and doesnt have any habits of smoking and alcohol consumption. She actually no

    known family medical history of hypertension, diabetes mellitus and etc. She was now at her

    second pregnancy PU 34 3/7 weeks AOG by her last menstrual period of January 01, 2010 and

    possibly via normal delivery. She is currently not taking any medications but she was having

    monthly and weekly prenatal check-ups in their Barangay health center and also for

    immunization.

    HISTORY OF PRESENT ILLNESS

    Three days prior to patients admission, Mrs. UTI noted having hypogastric tenderness with pain

    and discomfort with no associated signs and symptoms until one day of prior to admission

    patient felt hypogastric pain and tenderness which is now associated with inability of walking

    which was her chief complaint. She was on her second pregnancy after a number of tests and

    examination by her admitting physician Dr. Dr. Salayog, Benjamin Jorge she as admittedly

    diagnosed with UTI, she was referred to her now attending physician/OB-gyne to supervise her

    now condition. She was transferred to the labor room for monitoring of fetal heart rate as well as

    to alleviate uterine contraction through tocolysis.

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    PHYSICAL ASSESSMENT

    Physical examination follows a methodical head to toe format in the Cephalocaudal assessment.

    This is done systematically using the techniques of inspection, palpation, percussion and

    auscultation with the use of materials and investments such as the penlight, thermometer,

    sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure,

    the group made every effort to recognize and respect the patients feelings as well as to provide

    comfort measures following appropriate safety precautions and patients privacy.

    A. General Physical Assessment

    Mrs. UTI stands 54, with a pulse rate of 91 beats per minute, respiratory rate of 20 cycles per

    minute, a blood pressure of 110/60mmHg and a temperature of 36.7 C. She is conscious and

    coherent upon interaction. She is in a complete bed rest without bathroom privilages, in a

    trendelenburg position with pillows under buttocks and lower legs with stable condition but in

    tolerable pain.

    B. Assessment of the Head

    Head is round in shape (normocephalic). Hair is long in length, thick and coarse, straight and

    evenly distributed over scalp. There is no presence of abrasions, lice or any infiltrations.

    C. Assessment of the Eyes

    Her eyes are proportioned, brown in color, round shape. Pupils constricts when diverted to light

    (PERRLA) and dilates when he gazes afar, conjunctivas are pink. Eyelashes are equally

    distributed and skin around the eyes is intact. The eyes involuntarily blinks.

    D. Assessment of the Ears

    Ears are clean, no ear wax was noted and approximately of the same size and shape. Patient can

    hear normally when spoken softly.

    E. Assessment of the Nose

    With narrow nose bridge. No swelling of the mucous membrane and presence of nasal hairs were

    seen.

    F. Assessment of the Mouth

    She has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are

    pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is

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    free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon

    observation.

    G. Assessment of the Neck

    Neck has strength that allows movement back and forth, left and right. Patient is able to freely

    move his neck. Darker in color compared to other area of the skin maybe related to her

    pregnancy.

    H. Assessment of the Lungs and Thoracic Region

    No reports of pain during the inhalation and exhalation. There is an absence of adventitious

    sounds upon auscultation. Respiratory rate 18 breathes per minute from the normal range of 16-

    20 breaths per minute.

    I. Assessment of the Heart

    There is a visible distribution of hair from the chest wall.Patient has an audible heart sound upon

    auscultation of the S1 and S2 caused by the closure of the valves. Heart is pumping well with a

    pulse rate of 91 bpm from the normal rate of 60-100 beats per minute.

    J. Assessment of the Abdomen

    Upon inspection on the skin of the abdomen is uniform in color and slightly lighter than exposed

    areas and globular in shape with a fundic height of 32 centimeters. There are striae gravidarum

    and linea nigra along the abdomen. There is a active bowel sound upon auscultation. Abdominal

    movement as with respiration. With presence of fetal heart tone in Right lower quadrant (FHT:

    158 BPM)

    K. Assessment of the Upper Extremities

    Skin: White in color. Skin is smooth, moist and soft to touch with good skin turgor.

    Theres a presence of edema along the lower legs . Skin is warm to touch.

    Hands: Medium in size with 5 fingernails in each side. Nails are light pink in color,

    smooth and firm to touch short with brisk capillary refill of 1-3 seconds.

    Arms: Able to move through active ROM. Able to extend arms in front or push them out

    to the side.

    L. Assessment to the Lower Extremities

    Size of the feet is undefined with lines on the sole, without presence of scars and lesions. Ten

    fingers are present. Patient was unable to move one of his legs due to presence of pain below the

    hypogastric area maybe possibly in her pelvic brim leading to inability to walk comfortably.

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    M. Assessment of the Genitourinary

    She urinates infrequently (difficulty on urination). She has a bright scanty amount of yellow

    urine. There is the urgency of urination but unable to pass through urine (urinary incontinence).

    O. Neurological Assessment

    BehaviorPatient is having a facial grimace due to pain but is conscious and coherent

    upon interaction.

    Motor FunctioningThe patient is unable to move her legs comfortably due to presence

    of pain. But she was able to extend arms in front and resist active as pushed down/up on

    her hands.

    ReflexesSome of the reflexes were noted such as blinking, coughing or gag reflexes

    are present.

    Sensory Functioning Patients sensory system is intact, she was able to distinguish

    touch, pain, hot and cold.

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    ANATOMY ANDD PHYSIOLOGY

    Kidneys

    The role of the kidneys is to cleanse the blood and balance its fluids:

    They manufacture urine to filter out substances that the body does not need. They also take nutrients and other substances from the urine and return them to the blood.

    Urine is manufactured in the kidney's renal tubules. There are approximately one million of these

    in each kidney. The raw material the body uses to manufacture urine is filtered blood serum,which is the plasma portion of the blood (minus proteins and blood cells).

    The renal tubules process the filtered blood serum and remove the substances that willbecome urine These tubules lead into collecting ducts. These ducts empty the urine into small chambers referred to as renalcalyces he calyces funnel the urine into the renal pelvis, a basin-shaped cavity at the base of each

    kidney.

    Ureters

    The ureters are tubular organs that lead from the renal pelvis of the kidney to the bladder. The

    ureters transport small quantities of urine when their muscular walls contract rhythmically. This

    pushes the urine in a wave-like fashion through the ureters from the kidneys to bladder.

    Bladder

    The bladder is a storage organ for urine. The bladder wall has the capacity to stretch like aballoon, enabling the bladder to expand as the volume of urine increases.

    When enough urine is in the bladder, receptors that respond to the stretch in the bladder wall will

    send electrical signals to the brain. This creates the need to urinate.

    Urethra

    The urethra is a tubular organ that transports urine from the bladder to the outside of the body.

    In men, the urethra runs through the penis. In women, the urethra has its own opening within the vagina

    Inside the body, the urethra is surrounded by a muscle that a person can control. This musclemust relax in order for urination to occur.

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    PATHOPHYSIOLOGY

    Physiologic changes during pregnancy

    predispose such women to bacteriuria

    Urinary retention caused by the weight of

    the enlarging uterus. The uterus sits directly

    on top of the bladder. As the uterus grows,

    its increased weight can block the drainage

    of urine from the bladder

    Invasion of bacteria such asEscherichia coli (most

    common, in as many as 70% of cases) which was

    originated from fecal floras that colonize the

    periurethral area (ascending infection)

    Predisposing factors:

    Poor hygiene

    Poor intake of water

    Inadequatenutritions

    Sexual Intercourse

    Physiologic changes

    in pregnancy

    Leading to different signs and symptoms of infection:

    Feeling an urgent need to urinate or frequenturination.

    Having difficulty urinating.

    Having a burning sensation or cramps in the lower

    back or lower abdomen.

    Having a burning sensation during urination.

    Urine that looks cloudy or has an odor.

    Chills, fever, sweats

    IF TREATED:

    Medical management

    Nursing management

    Good prognosis

    Recovery

    IF NOT TREATED:

    It may lead to different complications such

    as:

    Kidney infections which may

    interfere with pregnancy, causing

    early labor and/orlow birth weight

    (pyelonephritis)

    Causing a permanent scar or

    damaged to kidney which can bedetrimental for both mother and child

    inside the womb.

    Sepsis

    DEATH

    http://www.amazingpregnancy.com/pregnancy-articles/115.htmlhttp://www.amazingpregnancy.com/pregnancy-articles/115.html
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    MEDICAL MANAGEMENT

    Suggested for some routine diagnostics examinations such as urine analysis and cultureand sensitivity tests which is safer tests for pregnancy to determine if pus, red blood

    cells or bacteria are present and to analyze the causative agent present and antibiotics

    which can be suggested to certain strains of MCO.

    Requested for some other examinations such as Complete blood count, platelet count,sodium-potassium, and pelvic ultrasound.

    Taking 3-7 day full course of antibiotics that is safe for the mother as well as to thebaby.

    Ampicillin 1gm IV q6 (-) ANST Increased oral fluid intake/hydration Monitoring of vital signs q4 Fetal heart tone monitoring q1 Ordered on Diet as Tolerated

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    NURSING MANAGEMENT

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    LABORATORY

    Laboratory #1: Urinalysis

    Result Normal Values Indication Nursing Management

    PhysicalColor Yellow Straw- Dark

    yellow

    Normal

    Reaction pH 6.0 4.6-6.5 Normal

    Transparency Sl. Hazy Sl. Hazy Normal

    Specific Gravity 1.020 1.016-1.022 Normal

    Chemical

    Albumin Trace (-) negative Albuminuria Monitor for signs andsymptoms of infection

    Monitor V/S Increase fluid intake Salt restriction

    Sugar (-) (-) negative Normal

    Ketones (-) (-) negative Normal

    Microscopic

    RBC 2-4/ HPF 0-2/HPF Hematuria Monitor intake andoutput.

    Monitor for signs andsymptoms of infection

    Monitor V/S Increase fluid intake Instruct don't resist the

    urge to urinate.

    Encourage Properhygiene

    Pus Cells 15-20/ HPF 0-2/HPF Bacterial

    infection

    Squamous Many (-) negative infection

    Bacteria Many (-) negative Bacterial

    infection

    Laboratory #2: SodiumPotassium

    Result Normal Values Indication Nursing Management

    Sodium 137.9 135-148 mmo/L Normal

    Potassium 3.27 3.5-5.3 mmo/L Normal

    Laboratory #3: Complete Blood Count

    Result Normal Values Indication Nursing Management

    WBC 9.6 4.0-10 Normal

    Segmenters 0.81 0.45-0.65 Increased,

    Infection

    Monitor intake and output. Monitor for signs and

    symptoms of infection

    Monitor V/S Increase fluid intake Instruct don't resist the urge

    to urinate.

    Encourage Proper hygieneLymphocytes 0.15 0.20-0.35 Decreased,

    Infection

    Monitor intake and output. Monitor for signs and

    symptoms of infection

    Monitor V/S Increase fluid intake Instruct don't resist the urge

    to urinate.

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    Laboratory #4: Pelvic Ultrasound

    Impressions:

    Single line intrauterine pregnancy, 35 weeks by fetal biometry.

    Cephalic presentation, with good cardiac and somantic activities.

    Somantic activities

    Anterior placenta grade II

    Normohydramnios

    Sonographic estimated fetal

    Weight is appropriate for gestational age.

    Encourage Proper hygiene

    Monocytes 0.04 0.02-0.06

    Eosinophils 0.00 0.02-0.04 Decreased,

    Infection

    Monitor intake and output. Monitor for signs and

    symptoms of infection Monitor V/S Increase fluid intake Instruct don't resist the urge

    to urinate.

    Encourage Proper hygieneBasophils 0.00 0.00-0.005

    RBC 3.22 3.9-5.6

    Hemoglobin 105 115165 Decreased Monitor intake and output. Monitor for signs and

    symptoms of infection

    Monitor V/S Increase fluid intake

    Instruct don't resist the urgeto urinate. Encourage Proper hygiene

    Hematocrit 0.31 0.36-0.47 Decreased Monitor intake and output. Monitor for signs and

    symptoms of infection

    Monitor V/S Increase fluid intake Instruct don't resist the urge

    to urinate. Encourage proper hygiene

    Platelet 221 150-350 Normal

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    DISCHARGE PLANNING

    Medications

    Instructed to follow prescribed medications and advised to avoid taking over the counter

    medicines without doctors prescription thus it will affect her child inside the womb.

    Exercise/Activities

    Participation in exercise, including kegel exercise and deep breathing exercise , can enhance

    circulation and aid in the elimination of blood congestion in the pelvic area.

    Treatments

    The first step in treating urinary tract infections is prevention. Prevention measuresinclude drinking plenty of fluids, urinating as soon as possible when the urge is felt, and

    drinking cranberry juice, which may have infection-fighting qualities.

    For women, prevention measures include urinating promptly after having sexualintercourse, wiping the genital area from front to back after urinating or defecating, and

    not using douches or deodorant feminine products. These can be irritating to the genitals.

    Other treatments:o Treating Urinary Tract Infection by drinking water or fluids

    It is very important for your system to have a good flow of urine. This canbe done by consuming plenty of water. It cleanses your body by diluting

    and flushing out the unwanted substance.

    o Treating Urinary Tract Infection by Cranberry Juice Cranberry juice disallows bacteria to cling to the cell, which line the

    urinary tract. It is a great remedy to fight this infection. If you cannot have

    the cranberry juice directly you can mix it with apple juice to add some

    taste.

    Health teachings

    For women with recurrent UTIs, give the following instructions:a. Reduce vaginal introital concentration of pathogens by hygienic measures.

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    b. Wash genitalia in shower or while standing in bath-tub bacteria in bath watermay gain entrance into urethra.

    c. Cleanse around the perineum and urethral meatus after each bowel movement,with front-to-back cleansing to minimize fecal contamination of periurethral area.

    Drink liberal amounts of water to lower bacterial concentrations in the urine. Avoid bladder irritantscoffee, tea, alcohol, cold drinks, and aspartame.

    Out-patient/ Follow up

    Advise women with simple, uncomplicated cystitis that they do not require follow-up aslong as symptoms are completely resolved with antibiotic therapy. But still follows the

    doctors order in case of there is a follow up check up to ensure that are no presence of

    infection especially if the case is pregnancy.

    Diet

    Since bacteria that cause infections in your urinary tract cannot live in very acidicconditions, one of the suggestions you should heed if you are prone to urinary tract

    infections is to increase your intake of vitamin-C-rich foods and to drink citrus juices that

    have a lot of vitamin C. Not only will this increase the acidity of your urine, it will also

    make you more resistant to infection.

    Some foods may have to be avoided when you have UTI, and these include processed

    foods, cheeses, and other dairy products. You may also need to avoid chocolates, coffee,

    and tea that have high caffeine content.

    Other things you may need to avoid when you have urinary tract infections include spicyfood, fizzy drinks or soda pop, beer, and other alcoholic beverages.

    Try to increase your intake of healthy substances like vegetables and fruits. You can alsohave these in fresh juice form by juicing them or pureeing them. You can also mix fruit

    and vegetables in one healthy juice that you can drink every day for your health.