Case Study

On

Urinary Tract Infection

OBJECTIVES: At the end of my case study, I will be able:

To determine what Urinary Tract Infection is; the pathophysiology and treatment that can be done to prevent it. To identify signs and symptoms of Urinary Tract Infection. To help patient promote health and medical understanding of such condition through the application of the nursing skills.

Introduction

A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract. However, this is the broad definition of urinary tract infections; many authors prefer to use more specific terms that localize the urinary tract infection to the major structural segment involved such as urethritis(urethral infection), cystitis(bladder infection), ureter infection, and pyelonephritis (kidney infection). Other structures that eventually connect to or share close anatomic proximity to the urinary tract (for example, prostate, epididymis, and vagina) are sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. UTIs are common, more common in women than men, leading to approximately 8.3 million doctor visits per year. Although some infections go unnoticed, UTIs can cause problems that range from dysuria (pain and/or burning when urinating) to organ damage and even death. The kidneys are the active organs that, during their average production of about 1.5 quarts of urine per day, function to help keep electrolytes and fluids (for example, potassium, sodium, water) in balance, assist removal of waste products (urea), and produce a hormone that aids to form red blood cells. If kidneys are injured or destroyed by infection, these vital functions can be damaged or lost. The most common causes of UTI infections (about 80%) are Escherichia coli bacterial strains that usually inhabit the colon. However, many other bacteria can occasionally cause an infection (for example,Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcus, Mycoplasma, Chlamydia, Serratia and Neisseria spp) but are far less frequent causes than E. coli. In addition, fungi (Candida and Cryptococcus spp) and some parasites (Trichomonas, Schistosoma) also may cause UTIs; Schistosoma causes other problems, withbladder infections as only a part of its complicated infectious process. In the U.S., most infections are due to Gram-negative bacteria with E. coli causing the majority of infections. There are many risk factors for UTIs. In general, any interruption or impedance of the usual flow of urine (about 50 cc per hour in normal adults) is a risk factor for a UTI. For example, kidney stones, urethral strictures,enlarged prostate, or any anatomical abnormalities in the urinary tract increases infection risk. This is due in part to the flushing or wash-out effect of flowing urine; in effect the pathogens have to "go against flow" because the majority of pathogens enter through the urethra and have to go retrograde (against a barrier, urine flow) to reach the bladder, ureters, and eventually the kidneys. Many investigators suggest that women are far more susceptible than men to UTIs because their urethra is short and its exit (or entry for pathogens) is close to the anus and vagina, which can be sources for pathogens. The UTI symptoms and signs may vary according to age, sex, and location of the infection in the tract. Some individuals will have no symptoms or mild symptoms and may clear the infection in about two to five days. Many people will not spontaneously clear the infection; some of the most frequent signs and symptoms experienced by most patients is a frequent urge to urinate, accompanied by pain or burning on urination. The urine often appears cloudy and occasionally reddish if blood is present. The urine may develop an unpleasant odor. Treatment for a UTI should be designed for each patient individually and is usually based on how sick the patient is, what pathogen(s) are causing the infection, and the susceptibility of the pathogen(s) to treatments. Patients who are very ill usually require IV antibiotics and admission to a

hospital; they usually have a kidney infection (pyelonephritis) that may be spreading to the bloodstream. Other people may have a milder infection (cystitis) and may get well quickly with oral antibiotics. Still others may have a UTI caused by pathogens that cause STDs and may require more than a single oral antibiotic. The caregivers often begin treatment before the pathogenic agent and its antibiotic susceptibilities are known, so in some individuals, the antibiotic treatment may need to be changed. In addition, pediatric patients and pregnant patients should not use certain antibiotics that are commonly used in adults.

NURSING ASSESSMENT Patient AB, a 42-year old man, a soldier for the Philippine Air Force was born on July 4, 1969, was admitted to Philippine Air Force General Hospital last August 24, 2011 with a chief complaint of having fever and chills. He was diagnosed with urinary tract infection (UTI) and was given Paracetamol for his fever and Co-trimoxazole as antibiotic. GORDONS ASSESSMENT Health Perception and Management Patient A.B prior to admission considered that he was in tip-top shape. He exercised everyday because being part of the army required daily training. He was deployed in different parts of the Philippines and said that he enjoyed his job despite all the risks. 3 days prior to admission, patient AB felt pain during his urination and decided to have a check up and was advised to be confined in Philippine Air Force General Hospital. Nutrition and Metabolism Before hospitalization He eats three times a day with 2-time snacks, in the morning at around 9am and in the afternoon at around 3pm. According to him he eats foods that are being prepared; he is not choosy in terms of eating. He made verbalized that he takes soft drinks or juices twice a day, included to these is water. In a day, he takes approximately 4 litres of water. According to him, he takes supplemental vitamins During Hospitalization He said that his appetite has never decreased, and he still eats three times a day or whenever food is brought to his room although his oral intake of water slightly decreased to 2-3 litres of water. Elimination Before hospitalization The patient did not specify how many times a day he urinates but he made mentioned that he urinates frequently a day which measures approximately cup every urination. His urine is yellow amber in color. He mentioned that whenever he feels that he wants to urinate, he tries to stop that feeling and finish first what he is doing before urinating. 3 days prior to hospitalization, he feels a little/slight pain during urination, the pain according to him was in the 4th level of the pain scale, 10 as the highest and 1 as the lowest. He defecates 1-2 times a day with brown stool. During hospitalization The patient stated that he urinates frequently around 10-12 times with a measurement of of a cup a day with a yellowish color, he feels slight pain during urination, and the level of the pain in pain scale is the same with before hospitalization. He defecated once during my shift.

Activity and Exercise Before Hospitalization The patient used to jog early in the morning, he was part of the air force and he considered their training as his form of regular exercise. During Hospitalization Since the patient is on IV therapy, his only form of exercise is to walk around the room and flexing his arms and legs. He is able to perform his usual ADL except jogging since his IV limits him to just walking around.

Sleep and Rest The patient completes 5-6 hours of sleep every night. He goes to bed as early as 11pm to 12mn and wakes up at around 5am or 6am for work. And the same sleep cycle if he has no work.

Coping and Stress Management The patient said that being in the hospital is what stresses him, he was very anxious to be released because he finds that his environment does not suit his interests. Values and Beliefs The patient is roman catholic. He attends mass every Sunday and believes that God is the center of his life. Through all this hardships serving in the philippine army, he believed that God has helped him through all of it.

PHYSICAL ASSESSMENT Physical assessment was not performed on patient; sample of Physical assessment. ASSESSMENT Appearance and mental status Body build, height, weight Posture and gait, standing, sitting and walking Overall hygiene and grooming Body and breath odor Facial expression Attitude Quantity of speech, quality, and organization Skin Color Lips, palms, soles Moisture Temperature Light brown; pinkish Lighter-colored Moist 37.3 Normal Normal Normal Normal FINDINGS INTERPRETATION

Proportionate according o lifestyle Relaxed, erect posture; coordinated movements Clean, neat No body odor; no breath odor Smiling cooperative Understandable, moderate pace, specific

Normal Normal Normal Normal Normal Normal

Skin turgor Texture Nails Fingernail plate shape Color Capillary refill Hair Distribution Texture Skull and Face Size, shape and symmetry Facial feature Facial movements Eyes Eyelashes Eyebrows Eyelids Conjunctiva Sclera Cornea Pupils Iris Ears Ear Canal opening Nose Shape, size, color Nares

Skin snaps back after 3-4 seconds smooth Convex curature Pink Returns to pink when pressure is released 3-4 sec

Normal Normal Normal Normal

Evenly distributed Smooth and straight

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Rounded, smooth skull contour Symmetric facial feature Symmetric facial movements Equally distributed; curved slightly outward Hair evenly distributed Skin intact; no discoloration Transparent with light pink color White color Transparent, shiny Brown, constricts briskly Clearly visible Free of lesions

Smooth, symmetric with same color as the face Oval, symmetric and without discharge

Normal Normal

Mouth Lips Gums Tongue Teeth Neck Symmetric, muscles, alignment of trachea Neck rolls Thyroid gland Trachea Thorax and Lungs Shape and symmetry of the Pink, moist, symmetric Slightly pink in color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Shiny and white of enamel Normal Normal Normal Normal Neck, slightly hyper extended, without masses or asymmetry Neck moves free without discomfort Neck moves freely without discomfort Rises freely with swallowing Chest symmetric Normal Normal Normal Normal Normal

thorax Spinal alignment Breathing patterns Abdomen Skin integrity Symmetry Abdominal movements Bowel movements Vascular Peritoneal friction rubs Percussion of abdomen Palpation of the abdomen Bladder Upper extremities (right and left) Radial pulse Skin integrity Lower extremities(right and left) Symmetry Skin integrity Skin color

Spine vertically aligned Quiet, rhythmic, and effortless respirations Unblemished skin, uniform color Rounded Symmetric movements caused by respiration Audible bowel movements Absence of arterial bruits Absence of friction rub Tympany over the stomach,gasfilled bowel; dullness especially over the liver and spleen No tenderness, reflexed abdomen with smooth, consistent tension Not palpable Equal pulsation Intact condition of the skin in arms, no lesions, no swelling

Normal Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Bilaterally symmetrical and equal Right and left foot has no lesions and has no swelling Same as the other part of the body

Normal Normal Normal

ANATOMY AND PHYSIOLOGY

The Urinary System

The function of the urinary system is to remove waste products from the blood and eliminate them from the body. The principal waste products being eliminated are water, carbon dioxide and nitrogenous wastes including area, uric acid and creatinin. Other functions of the urinary system include the regulation of the volume of body fluids, the balance of pH and the electrolyte composition of these fluids. Kidneys The kidneys are located in the back of the upper abdomen and are protected by the lower ribs and rib cartilage of the back. The kidneys are involved with a number of bodily functions which include:

The filtering and excretion of unwanted waste products such as urea from the body. The maintenance of water balance. the regulation of the acid-base balance of body fluids. the production of renin, which is important in the regulation of blood pressure. The production of the hormone erythropoieten, which stimulates the production of red blood cells.

Ureters The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder. Bladder The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder. Urethra The urethra is a tube that extends from the bladder to the outside world. It is through this tube that urine is eliminated from the body. AFFECTED SYTEM: Urinary System AFFECTED AREA: Urethra

Pathophysiology

Non-modifiable factors: AGE UTI is a prevalent disease among children and elderly SEX it has a higher incidence rate with the female gender

Modifiable factors: Inadequate access to toilet facilities Avoidance of the urge to void Urinary catheterization Fistula between the intestine and bladder Inadequate fluid intake Pregnancy and DM

Bacterial invasion (i.e. E.coli)

Multiplication of the bacteria causing UTI in any part of the urinary tract Interruption in the normal homeostatic environment of the urinary tract Immune response by the body (defens emechanism of the body to foreign bodies) Increased WBC subsequent to pus formation Change in urine color

Cytokine and prostaglandin release Body induces the action of the cytokines and prostaglandins Cytokine andprostaglandin release

The body responds by producing physiologic changes aimed at elevating body temperature. Fever

Inflammation of the lining of the urinary tract

Irritation of the lining of the urinary tract

Narrowed urine passage

Urethritis and dysuria

Urinary spasm of the bladder

Poor emptying of the bladder Urinary incontinence Frequent urination and urgency, and nocturia

List of Priorities: Pain Fever

 Risk for Infection

Nursing Care Plan Assessment Subjective: Masakit yung pagihi ko. As verbalized by the patient Objective -Facial grimace. -Restlessness. V/S taken as follows: T: 37.3 P: 82 R: 19 BP: 120/90 Diagnosis Acute pain related to biological factors such as trauma or activity of disease process Planning After 8 hours of nursing interventions, the patients pain will be relieved or controlled. Intervention Independent: -Assess pain, noting location, intensity (scale of 0 10), duration. -Encourage increased fluid intake. -Investigate report of bladder fullness. -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 of sitz baths, warm soaks to the perineum. Collaborative: -Administer antibacterial as prescribed. Evaluation After 8 hours of nursing interventions, the patients pain will be relieved or controlled.

Assessment Subjective: Ang sakit ng ulo ko, tapos nilalagnat pa ako. As verbalized by the patient Objective -weak -skin hot to

Diagnosis Hyperthermi a related to increased metabolic rate evidenced by increased in body temperature.

Planning After an hour of good nursing intervention the patients temperature will decrease from 38.2 to 37.8.

Intervention -Monitor patients temperature; noting shaking chills. - Perform Tepid Sponge Bath -Increase fluid intake -administer medications as

Evaluation After an hour of good nursing intervention that patients temperature decreased to 38.2

touched -restlessness Temp = 38.2

prescribed by doctor

DRUG STUDY Drug Name Generic Name: Co-trimoxazole Brand Name: Bactrim Indication Uncomplicated UTIs caused by susceptible strains of E. coli, Proteusmirabilis, Klebsiella pneumoniae, Enterobacter species, and coagulasenegative Staphylococcus species, including staphylococcuss aprophyticus Treatment of acute otitis media due to suscep tiblestrains of S. pneumoniae and H. influenza in children Contraindication Allergy to trimethoprim, pregnancy (teratogenic in preclinical studies), megaloblastic anemia due to folate deficiency. Nursing Responsibilities -Assess allergic reactions -Monitor I&O ratio -Monitor kidney function -Assess type of infection -obtain C&S before starting therapy -Assess blood dyscrasias

DISCHARGE PLAN M-edication Instruct patient about the proper way of taking his medicines and the actions of each medication in a manner that the patient can easily understand and emphasizing the importance of following the prescribed medication. E-conomic Inform patient about the generic name of his medications. Thus informing them that they can save money buying generic drugs T-reatment Advice patient to follow all prescribe medications. Encourage also to increase fluid intake tolerated by the pt. H-ygiene Educate patient about his disease, how they can prevent it to happen again. Encourage to increase fluid intake and fruit juices intake as well.

O-ut Patient/follow-up Inform that he should have a follow-up check-up after 1 week to his AP clinic D-iet Educate client that his diet is as tolerated but emphasizing the need to increase his oral fluid intake.