Nursing Case Study Uti

8/2/2019 Nursing Case Study Uti

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I.

A urinary tract infe~oiP I) is a bacterial infectiont that affects any part of theurinary tractc one contains a variety of fluids, salts, and waste products, itusually bacteria in it. When bacteria get into the bladder or kidney andrine, they cause a UTI. The most common type of UTI is a bladderich is also often called cystitis. Another kind of UTI is a kidney infection,as pyelonphritis, and is much more serious. The major problem ~ is thatS rinary tract infection causes discomfort and pain on urination. ~%~~ ' \ ) \ )

Incidence: ~ ~~~ .,Most common renal disease in children. ~Almost 10 times more common in femal~ es, except in the neonatal~7a~~~ris the most commo~' ~~~~n25%of all women (Cystit~'S ~v\) .Men before the age of 5Risk Factors:Location of the female meatusSexual intercourseUrinary stasis and reflux in pregnant women caused b~ssure on the uretersand hormonal changes. ~((>~~\)\)Tight and synthetic clothing (causes irritatio~ ~~Presence of an indwelling catheter. ~~~~"S .,

~~~~A'Gen~~~At the ~ my duty in the World Citi Medical Center, I, Aristotle R........... ...

3 rd yr. Bache'tor of Science in Nursing student of WCC-QC , will be 1 rtmy acquired knowledge and skills towards the patient, t~~ ing andmaintaining, physiologic and psychologic stability, an~~~ation.

B. Spectflc objectives ~~rfEstablish a trusting retatrii'nru~'ii:-ll'tl',:~nt and his family.Perform the assigned t -ntly and dynamicallyFormulate an effective ng care plan for the client regarding UTI.assessing the signs and symptoms of patient

Acquire necessary skillswith UTI.


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Internalize the ne s t or principle regarding UTI. Educate th~~V\J prevention, promotion, and maintenance ofhealthiiYif '~ as to cure and restore health.

\) \jc. TB~ amework\\~~';;~efinition of Nursing~~~: Virginia Henderson's definition of the unique functio0 5 a major stepping stone in the emergence of nursing asfrom medicine. Like Nightingale, Henderson describeclient, and client's environment. Unlike Nightin; ~' n saw that nursesinteract with clients even when recovery mct\~ asible, and mentionedthe teaching and advocacy role of nurseQ ~~Henderson concePtuaLize~~~roLe as assisting sick or heaLthyindividuals to gain indepe~'$>\)~ng 14 fundamentaL needs.

1. Breathing normal~2. Eating and drinki~"'dequately.3. Eliminating body wastes.4. Moving and maintaining a desirable position.5. Sleeping and resting.6. Selecting suitable clothes.7. Maintaining body temperature withinand modifying the environment.8. Keeping the body clean and to protect the integument9. Avoiding dangers in the and avoiding injuring others10.Communicating wi expressing emotions, needs, fears, oropinions ~11.Worshi ., I\d&lgo one's faith12.WorK way that one feels a sense of accomplishment13. Pla . rticipating in various forms of recreation ~14. Lear g, discovering, or satisfying the curiosity that leads t ldevel pment and health, and using available healthfacilities. ~~\l

I chose Henderson's theory because it SUites~mp- .~~The above 14 fundamentals are necessary fo . recovery as wellas healthy persons. 0~Breathing normally is essentia~l for ~ . cause it is the most vitalneeded for our body. Proper die is l~ . pr ent malnutrition and theoccurrence of the disease. Dri . . .' tly is needed for a sick individualfor fluid replacement. Prop . on is important to prevent toxicities inour body. Patient needs to r . ion on their desirable position, to promotecomfort and to prevent pneum ia. Individuals are required to have adequate


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rest in order for thel.r b~~-""\:}_ ~~!gth. Proper clothing can promoteclients comfort. c~Sick person .. ave a cool and proper ventilated environmentbecause th~ .. their recovery. During patient hospital confinement,nurses ~ to observe safety for the patient by doing safetye ,~~. ea care provider may also implement nurse- patient, this will encourage patient to express her or his emotions, fears, orns. ~

. This theory conceptualized both the sick and healthy P S c : . . t is adynamic care especially during the stage of illness.@),~%~~

II. NURS ING ASSESSMENT :~ ~ ~~~~~

~\~A . Personal Data

Patient's Name: F . eAge: 2 yrs. oldBirth date: November~;:::ess: ~~~it~ santoln, pasig cityReligion: < : > ~ ~ athoticCivilStatus: ~~~~ Child;:~~~:Time of Admission:Admitting Diagnosis:Notice of Admission:HowAdmitted:Admitting Physician:


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\ ' )%~~.:...:..:.=.::...=..:....:....::.:..:...:...:~ ~~\l

nt maximum temperature at 40.4 C not relieved10 ml dose. Dry non-productive cough and colds also'l'l}f;>aYmwith lovicol SOmlTID with night relief.

Patient was hospitaLized at the age of 1 year L~~%~! TractLnfection Last2006. 0 ~~~ Ij

Chief CompLaint: Fever 0 ~~~~Urin~ ection.iagnosis:

C. 13 Areas of Assessment

A. ~:~:aL Appearance \\ ~~~Patient has a white oompleXi~~~kin.

Head F.~~he head is r . ~~, s no Lesion observed. The patient has smooth,short curly b. .. eared well combed although oily.

~.~ .. ~n. t. h.as. rounde.d .eyes wi.th w.h.ite sclera and pinkish conju~a,1~'eere black and equally rounded. ~~\)\>Nose ~~~~The nose is flat and small, there's no infl.~1\~ ~~r lesion butthe internal mucosa was wet due to her ~OldS~'(J~~"0S .Ears ~~

The ears are clear and o~~~' I I l ' ill -r cantus of the eyeMouth , u ~ ~ ~ ki h i 1 h' ' her IesiPatient s IpS are u pin IS III co or, t. ere s nert er esions nor

ulcerations found, gums and tongue looked pink in color,


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~t0~~2.) M ENTAL STA TUS i\~~~~ Alert ~~~~ Conscious \) ((\~~~ Can speak "dada" or "mama", and~~~cific words. Turns toward sounds o~~~?i)'03.) EMOT IONAL STATUS ~

Speech:

Grand Mother3 (reliable)

Calm


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Eyes are symmetricaL ~%~~~~\) ~~\J

Absence of~6i>. .~~ No fre~~1?!ifing

=r=, Doe~e any hearing aids. No ;i~argeS from ears, no nodules, lesions, and no pain. Ears are symmetrical and were proportionate to his head. Can distinguish hot fro~,~~~m miLk).

Speaks uncle ~lks) High R ! t

~~~~

Creeps on hands and knees \\\\~ '\) Sits alone \) ~~~\Y Pulls self to standing position ~\\~~ Takes a rattle by his hands ~d R~~v A.b.le to pass rattle han~. . ~Kes crude pincer grasps). Tries to get a toy out \j RO M: Not Full

Smell:

Touch:

Speech:


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Muscles are fleXibl~~~! Sat alone at a~~~ ~~\)\Jj months Rolled ove: ~"0S 4 months w . al~~~ 9 months with support

~~: Not practiced yet\) g: . No~ practiced yet

~ mance: FmrDecreased performance and reports of weakness ye~~ thefather). ~~ ~

6.) BODYTEMPERATURE 0 ~~~~Bodytemperature: 37~~~~~ft axilla asof April 13, 2007.

7.) RESPIRATORYSTf Respiratory rate is 32 cpm; Rhythm is regular. No wheezes

o ~~ \ J~E x t ~ e ~ ~ : ~ : i Pink lower extremiti~,\~~~ Capillary refill time: 2 seconds. ~9~~ Nails: Pink ~~~

Distribution! Qpality of Hair: ~~.CO(~r: Overall: ~ complexion

Flushed skin

~%\J~8.) ClRCULATORYSTATUS @;: ,~~~. s Heart rate: 118 bP~~~ 09,2007 Rhythmis ~~~': ~~~s~e: ~~ No oted. Febn .

No rales.


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~% \ )~ Mucous mem~~~~~ ~ l~k Nail.~beds: ~~ Pink Can] ~ Pink s~ White

~TRITIONALSTATUS ~ Breast feed and formula feeding diet: (Enfapro and~~(j No trouble in swallowing ~~~\'j Able to chew and masticate food. ~~ \ : 2 J Good appetite: he. can con~me of milk per day, andbreastfed during day and night tt . \ J He usesdistilled drink~ngw~ Weight: 20.2~~ Color of tongue is ~~~h pink Ups are pink and not dry Condition of teeth and gums: Good, intact, an No food allergy. ~ Eruption - upper LateraLincisors ~~~

Immunization: \)\\\\~~~ BCG ~~0~ DPT I, II, III ~\\0~~: OPV~~~\'~

~E LIM IN AT IO N S TA TU S

Usual bowel pattern: Morning Character: Soft for ",, '. .,,~ .. .' I ' ' ' ' Bladder function in irregul Urgency ~ Color of urine: ~ yellow. Diaper changes: \S .4 per day. Dysuria

10.)


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father.] ~r : ? \ \ ~\ J \ ( : )~~R DUCT IV E S TA TUS

~%~~12.) STATE OF PHYSICAL REST AND CO~~~~ s s

Usual Activities: Pla~ cubes) Sleep: 16-~W

Sk;~:3.) STATE OF ~ENDEGES Fair complexion Flushed skin, warm to touch. Warm upper and lower extremities. Preferred time of bath: Moming w~ Good skin turgor. ~%~\;:;\)\)

Ha;~: Wavy and clean cut \'i~\\~~~, Dark brown in colol) ~~~~~ Fine and thin ~~~~

Scalp: ~~~~ Int!~~ No, g noted ~ No sc p lesions ~; ~~~\) Anterior fontanel remains open and posterior fonta~~\'>'\J .

Nails: h \ \ ~~ \ : : 5 Fingemails are short cut and pink in c~o ~~~~ Toenails are cut short and well tri~ ~

~~~-

Male Uncircumcised


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IV. ANATOMYAND P~'fI,n!Q.",,~~~~~~~-~ ~ 1 ! f ! j 3 Front View of Urinary Tract

~~~

bladder

How does the urinary system work?The body takes nutrients from food and converts them to e~~ter the body hastaken the food that itneed" waste products are left ~i~~wel and in the blood.The urinary system keeps the chemicals~a. d .. ~);2e by removing a type ofwaste, called urea, fr.omthe blood. u~e '. ,D . hen foods containing p.rotein, s.uchas meat, poultry, and certain vegetr!\~' en down in the body. Urea is carried inthe bloodstream to the kidne5t)j~~

two air of purplish-brown organs located below the ribs toward themiddle ~ ack. Their function is to: ~

remove liquidwaste fromthe blood in the formof urin:~~~\Jkeep a stable balance of salts and other subStr$.q~~Wod.

cells. produce erythropoietin, a hormone_~~::::n of red blood

The kidneys remove urea fro h. ~ tiny filtering units callednephrons. Each nephron con . ormed of small blood capillaries, called aglomerulus, and a small tube .~ renal tubule. Urea, together with water andother waste substances, forms urine as it passes through the nephrons and downthe renal tubules of the kidney.


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two ureters - narro ~~!rom the kidneys to the bladder.Muscles in the ure r ~ally tighten and relax forcing urine downward,away from the ki me backs up, or is allowed to stand still, a kidneyinfectiorrc ~ out every 10 to 15 seconds, small amounts of urine are

f' dder from the ureters.\) - a triangle-shaped, hollow organ located in the lower abdomen. It is

~~ place by ligaments that are attached to other organs and the pelvic bones.0 ~ \ 0 . dder's walls relax and expand to store urine, and contract and fla~.; S empty urine through the urethra. The typical healthy adult bladd r c~~ totwo cups of urine for two to five hours. ~

two sphincter muscles - circular muscles that help c a . ~m leaking byclosing tightly like a rubber band around the ope~~~ der.bl,;:::e, in the bladder -alert a peTSo~~~ to urinate, or empty the

urethra - the tube that a~ {~~S outside the body. The brain signalsthe bladder muscles to ti queezes urine out of the bladder. At the sametime, the brain signals r muscles to relax to let urine exit the bladderthrough the urethra. Wh the signals occur in the correct order, normal urinationoccurs.

v . PATHOPHYSIOLOGYFor infection to occur, bacteria must gain acce~~oct]~'e'-{'il}3tt1der,ttach to and colonize theepithelium of the urinary tract to av i out with voiding, evade hostdefense mechanisms, and initiate in ost UTIs result from fecal organismsthat ascend from the perinen~ ra and the bladder and then adhere to themucosal surfaces. ~~\SBacterial InV~~'\\~ nary TractBy inCreaS!' ~~ow shedding of bladder epithelial cells (resulting in bacteriaremoval), - ladder can clear itself of even large numbers o~a.Glycosamino yean (GAG), a hydrophilic protein, normally exerts a tprotective effect against various bacteria. The GAG molecule at ractef\:- cules,forming water barrier that serves as defensive layer between th ~ ' c Ithe urine.GAG may be impaired by certain agents (cyclamate, saccha e, and trytophanmetabolites). The normal bacterial flora of the va8.&a a rea also interfere withadherence of Escherichia coli (the most commo ' sms causing UTI). Urinaryimmunoglobulio A (IgA) in the urethra may~ _ arrier to bacteria.Reflux c~~An obstruction to free-flowing u~' problem known as urethrovesical reflux, whichis the reflux (backward flow) of u~e from the urethra into the bladder. With coughing,sneezing, or straining, the bladder pressure rises, which may force urine from the bladder


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~~~~f""",~n\ ually congenital

eral reflux'0.iii1liiP:ct';lOnslsewhere in the body.) upper respiratory.) gastrointestinal diarrheapoor perineal hygieneshort female urethra ~ catheterization Inherent defect in the ability of the ~ d cosa toprotect it from microbial infectio . @ S ~ \0 \$

~~~~~?VI. LABORATORYI ~~'!MSPLATELET COUNT ' \ : SApril 14, 2007

Above 500 150-350 x 9 /L

COMPLETE BLOOD COUNTApril 14, 2007

ORMAL VALUES CLINICAL SIGNIFICANCE

5.00-10.00 x 9 /L t0.38-0.50 1 -

Neutrophil 0.20 0.02-0.080.73 0.40-0.60LymphocyteMonocyte 0.01 0.00-0.04Eosinophil 0.01 0.00-0.01


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CephalosporinCefuroxime Sodium

DOS AGE CON TRAIN D IC AT IO NHypersensitivity tocephalosporin. Acuteporphyria.

Cross allergy ofpenicillin

espiratory Childrenract, ENT, andrinary tract, infant:kin and soft 300-100

0 and, bone and mg/kg/ayin 3 to 4divideddoses. withdiuretics e.g.

furosemide andaminogLycosides.Anaphylacticreactionspenicillin.

rash,to pruritus andarthralgia.

pyrosis,abdominaLpain, veryseldom,urticaria orcutaneous


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\ 1 \ 1 J " " . r ~ r y Elimination, altered related to Urinary Tract

PLANNING NURSING RATIONALEINTERVENTION

Urinary After 4 hours INDEPENDENTElimination, of nursing NURSINGaltered intervention, FUNCTION:related to the patientUrinary will achieve" AssessTract normalInfection.

.. Review drug .. Some drugs mayregimen (no.e res~~ urinary

of d~ug re\~\>\)Vtoxi~ ~~ 0i s W . . UTI are more

prevalent in womenand older men.

.. To detect urinarydiversion.

ofmucus.

.. Reviewtests. lab .. To detecthyperparathy roidism,changes in Renalfunction.

Determinepatient'spreviouspattern ofelimination.

ine .. To assessconditionusual of skin and mucous

aily intake. membranes... Encourage * To help maintainfluid intake renal function,

EVALUATION

r 4 hoursnursingention,

goal is met.Patientachievednormaleliminationpattern .


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Assistde:,elopingtoiletingroutines asappropriate

" Keep diaperarea clean anddry.

" Recommendavoidance fgas ..0f. formingoods .medications orthat producestrong odor.

in

prevent .and f mfection. ormationunnary stones. of" To helpregular achievepattern. urination

acterial discouragewhen app .growthropnate.

To recognicomplicati mzeon,necessitatingmedicalintervention.

.. To promotecontrol. odor


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increased metabolic rate,

INDEPENDENTNURSING

FUNCTION:

flushed skin,arm to touch.

aincreasedmetabolicrate, due toillness ortrauma.

After 8hours ofNursingIntervention, patient .. Identifywill underlying cause.

ATA/CUES PLANNING NURSINGINTERVENTION

RATIONALE

maintaincoreI(ken areparticular riskpermanentneuroLogicdamage.To evaluate

ranges ofand temperature.

leveL of

.. Cardiac rate andECGchanges occurdue to electrolyteimbalance.

" Monitor " Hyperventilationmay initially bepresent. . ~. \"Olig~~~~f ~~~C~~

ension.

respiration

" Monitor/recordaU of

" Body attempts toincrease heat Loss.

" cool" To promoteenvironment, surface cooling.Provide

EVALUATION

After 8 hoursof nursingervention,is met.e patientmaintainedhis coretemperatureat withinfor normal rangeof 36.4(,


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bed " TometabolicdemandsoxygenconsumptiIOn.

reduceor

" For Infection.

supportvoLumetissue


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Prevention1.) Spread of bacteria from the anal an.~'~s to the urethra canbe minimized in female children ~~ng the perineal area fromthe urethra back toward the ~~\:2.) BU.bble bat.hs ShO.Ul~nQh.~~~ ecause of the bLadder irritanteffect of these olutis ~~~.3.) Encourage ade ntake, especially water.4.) Acidif th ces (e.g. cranberry juice).5.) E c to void frequently and to empty the bladderlA~~~~~vpw'theach voiding.6.) cotton underpants ~7.) T ing showers versus baths. ~\\>\)8.) Avoiding wearing pantyhose with slacks. ~%~9.) Washing the. perineal area before inter~~(C f a voiding

immediateLy after. . ~~ .

~~'f~~~

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Nursing Case Study Uti