Urinary Tract Infection

INTRODUCTION

A urinary tract infection (UTI) is a bacterial infectiont that affects any part of the urinary tract. Although urine contains a variety of fluids, salts, and waste products, it usually does not have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The most common type of UTI is a bladder infection which is also often called cystitis. Another kind of UTI is a kidney infection, known as pyelonphritis, and is much more serious. The major problem here is that urinary tract infection causes discomfort and pain on urination.

Incidence:

Most common renal disease in children.Almost 10 times more common in females than in males, except in the neonatal period.Bladder is the most common site of infection25% of all women (cystitis)Men before the age of 50 years

Risk Factors:

Location of the female meatusSexual intercourseUrinary stasis and reflux in pregnant women caused by pressure on the ureters and hormonal changes.Tight and synthetic clothing (causes irritation)Presence of an indwelling catheter.

A. General objectives

At the end my duty in the World Citi Medical Center, I, Aristotle R. Baricaua 3rd yr. Bachelor of Science in Nursing student of WCC-QC, will be able to impart my acquired

knowledge and skills towards the patient, through promoting and maintaining, physiologic and psychologic stability, and health restoration.

B. Specific objectives

Establish a trusting relationship to client and his family. Perform the assigned task efficiently and dynamically Formulate an effective nursing care plan for the client regarding UTI. Acquire necessary skills in assessing the signs and symptoms of patient with

UTI. Internalize the necessary concept or principle regarding UTI. Educate the family in the prevention, promotion, and maintenance of healthy

lifestyle as well as to cure and restore health.

C. Theoretical framework

Henderson’s definition of Nursing

In 1966 Virginia Henderson’s definition of the unique functioning of nursing was a major stepping stone in the emergence of nursing as a discipline separate from medicine. Like Nightingale, Henderson described nursing in relation to the client, and client’s environment. Unlike Nightingale, Henderson saw that nurses interact with clients even when recovery may not be feasible, and mentioned the teaching and advocacy role of nurse.

Henderson conceptualized the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs.

1. Breathing normally.2. Eating and drinking adequately.3. Eliminating body wastes.4. Moving and maintaining a desirable position.5. Sleeping and resting.6. Selecting suitable clothes.7. Maintaining body temperature within normal range by adjusting clothing and

modifying the environment.8. Keeping the body clean and well groomed to protect the integument9. Avoiding dangers in the environment and avoiding injuring others10. Communicating with others in expressing emotions, needs, fears, or opinions11. Worshipping according to one’s faith12. Working in such a way that one feels a sense of accomplishment13. Playing or participating in various forms of recreation14. Learning, discovering, or satisfying the curiosity that leads to normal

development and health, and using available health facilities.

I chose Henderson’s theory because it suites my patient.The above 14 fundamentals are necessary for a clients recovery as well as

healthy persons. Breathing normally is essential for a person because it is the most vital

needed for our body. Proper diet is crucial to prevent malnutrition and the occurrence of the disease. Drinking sufficiently is needed for a sick individual for fluid replacement. Proper elimination is important to prevent toxicities in our body. Patient needs to reposition on their desirable position, to promote comfort and to prevent

pneumonia. Individuals are required to have adequate rest in order for their body to regain strength. Proper clothing can promote clients comfort.

Sick person needs to have a cool and proper ventilated environment because this could help in their recovery. During patient hospital confinement, nurses are required to observe safety for the patient by doing safety precautions. Health care provider may also implement nurse- patient interaction, this will encourage patient to express her or his emotions, fears, or opinions.

This theory conceptualized both the sick and healthy persons. It is a dynamic care especially during the stage of illness.

II. NURSING ASSESSMENT

A.Personal Data

Patient’s Name: F.C

Age: 2 yrs. old

Birth date: November 04, 2004

Address: 233 concepcion st. santoln, pasig city

Sex: Female

Religion: Catholic

Civil Status: Child

Father:

Mother:

Date of Admission: April 13, 2007

Time of Admission: 7:11:05 pm

Admitting Diagnosis: Urinary Tract Infection

Notice of Admission: Emergency and Stable

How Admitted: Ambulatory

Admitting Physician: Cruz, Oliver V.

History of Present Illness:

Day 3 fever-intermittent maximum temperature at 40.4 C not relieved by paracetamol intake at 10 ml dose. Dry non-productive cough and colds also noted. Self-indicated with lovicol 50ml TID with night relief.

Past Medical History:

Patient was hospitalized at the age of 1 year old, due to Urinary Tract Infection last 2006.

Chief Complaint: Fever

Diagnosis: Urinary Tract Infection.

C. 13 Areas of Assessment

A. General Appearance:

SkinPatient has a white complexion with a clear skin.

Head

The head is round and there’s no lesion observed. The patient has smooth, short curly black hair. It appeared well combed although oily.

Eyes

The patient has rounded eyes with white sclera and pinkish conjunctiva. The pupils were black and equally rounded.

Nose

The nose is flat and small, there’s no inflammation, flaring or lesion but the internal mucosa was wet due to her colds.

EarsThe ears are clear and symmetrical to the inner cantus of the eye.

MouthPatient’s lips are dry and pinkish in color, there’s neither lesions nor ulcerations found. The gums and tongue looked pink in color.

NeckThe neck is symmetrical in shape, no palpable mass along the lymph nodes.

AbdomenThe abdomen is flat and soft upon palpation, and she has a normal abdominal bowel sound.

ExtremitiesThe patient’s hands and wrists are intact and has a complete set of fingers, She had no problems extending and flexing his forearm thus she can easily perform range of motion exercises.

1.) SOCIAL STATUS

Patient’s Name:. F. CAge: 2 years oldBirth date: No. 6, 2004 Sex: FemaleReligion: CatholicCivil Status: ChildFather: Mother:Address: 233 concepcion st. santolan, pasig city

Speech: Clear Indicates wants (e.g. food) Babbles vowels

Source of information: Grand MotherReliability: 3 (reliable)

2.) MENTAL STATUS

Alert Conscious Can speak “dada” or “mama”, and other nonspecific words. Turns toward sounds

3.) EMOTIONAL STATUS

Calm Smiles spontaneously Irritable (upon administration of medications)

Waves bye-bye. Initial anxiety towards strangers

4.) SENSORY AND PERCEPTION

Vision:

Eyes are symmetrical

Smell:

Absence of nasal drip No frequent nose bleeding

Hearing: Does not use any hearing aids. No discharges from ears, no nodules, lesions, and no pain. Ears are symmetrical and were proportionate to his head.

Touch: Can distinguish hot from cold (e.g. Warm milk).

Speech: Speaks unclearly (baby talks) High pitched voice Babbles vowels

5.) MOTOR ABILITY

Muscle mass/ tone: Thin built. Creeps on hands and knees Sits alone Pulls self to standing position Takes a rattle by his hands and bangs them Able to pass rattle hand by hand ;( makes crude pincer grasps). Tries to get a toy out of reach

ROM: Not Full

Muscles are flexible, soft, and tender. Sat alone at age: 9 months Rolled over: 4 months Walked: 9 months with support Toilet trained: Not practiced yet Dressing: Not practiced yet Performance: Fair

Decreased performance and reports of weakness (verbalized by the father).

6.) BODY TEMPERATURE

Body temperature: 37.8C taken via the left axilla as of April 13, 2007.

7.) RESPIRATORY STATUS

Respiratory rate is 32 cpm; Rhythm is regular. No wheezes No rales.

8.) CIRCULATORY STATUS

Heart rate: 118 bpm as of April 09, 2007 Rhythm is regular. Pulse: 118 bpm Full pulses No edema noted. Febrile.

Extremities: Color: Pink lower extremities Capillary refill time: 2 seconds. Nails: Pink

Distribution/ Quality of Hair: Fine, thin hair.

Color: Overall: Fair complexion

Flushed skin

Mucous membranes: Pink Nail beds: Pink Conjunctiva: Pink Sclera: White

9.) NUTRITIONAL STATUS

Breast feed and formula feeding diet: (Enfapro and Aulin) No trouble in swallowing Able to chew and masticate food. Good appetite: he can consume 6 bottles of milk per day, and breastfed

during day and night time. He uses distilled drinking water.

Weight: 20.2 kg.

Color of tongue is whitish pink Lips are pink and not dry

Condition of teeth and gums: Good, intact, and no bleeding.

No food allergy. Eruption – upper lateral incisors

Immunization: BCG DPT I, II, III OPV I, II, III Hepa B I, II, III Hib I, II, III

10.) ELIMINATION STATUS

Bowel function in regular pattern Usual bowel pattern: Morning Character: Soft formed stool. Bladder function in irregular pattern. Urgency Color of urine: Pale yellow. Diaper changes: 3-4 per day. Dysuria

Pain in urination [“Often times he cries during pee time” as verbalized by the father.]

11.) REPRODUCTIVE STATUS

Male Uncircumcised

12.) STATE OF PHYSICAL REST AND COMFORT

Usual Activities: playing (e.g. rattle, cubes) Sleep: 16-18 hours

13.) STATE OF SKIN AND APPENDEGES

Skin: Fair complexion Flushed skin, warm to touch. Warm upper and lower extremities. Preferred time of bath: Morning Good skin turgor.

Hair: Wavy and clean cut Dark brown in color Fine and thin

Scalp: Intact No flaking noted No scalp lesions

Anterior fontanel remains open and posterior fontanel is closed.

Nails: Fingernails are short cut and pink in color Toenails are cut short and well trimmed

IV. ANATOMY AND PHYSIOLOGY

How does the urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood.

The urinary system keeps the chemicals and water in balance by removing a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

Urinary system parts and their functions:

two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to:

remove liquid waste from the blood in the form of urine.

keep a stable balance of salts and other substances in the blood.

produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.

bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.

two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.

nerves in the bladder -alert a person when it is time to urinate, or empty the bladder. urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to

tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

V. PATHOPHYSIOLOGY

For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation. Most UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces. Bacterial Invasion of the Urinary TractBy increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder can clear itself of even large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming water barrier that serves as defensive layer between the bladder and the urine. GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and trytophan metabolites). The normal bacterial flora of the vagina and urethral area also interfere with adherence of Escherichia coli (the most common microorganisms causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria.

RefluxAn obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the

incidence of infection in postmenopausal women. Reflux is most often noted, however, in young children. Treatment is based on its severity.

Ureterovesical or vesicoureteral reflux refers to the backflow of urine from the bladder into one or both ureters. Normally, the ureteroveical junction prevents urine from traveling back into the urether. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach and eventually destroy the kidney

Loss 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

Route of entry:- Ascent from the urethra (most common)- Circulating blood.

Contributing causes: obstruction usually congenital vesicoureteral reflux infections elsewhere in the body

1.) upper respiratory2.) gastrointestinal diarrhea

poor perineal hygiene short female urethra catheterization Inherent defect in the ability of the bladder mucosa to protect it

from microbial infection.

VI. LABORATORY / DIAGNOSTIC EXAMS

PLATELET COUNTApril 14, 2007

RESULT NORMAL VALUES

CLINICAL SIGNIFICANCE

Above 500

150-350 x 9/L

COMPLETE BLOOD COUNTApril 14, 2007

EXAMINATION MADE

RESULT

NORMAL VALUES

CLINICAL SIGNIFICANCE

Hemoglobin 116 125.00-160.00 9/L

RBC Count 4.0 4.50-5.50 12/L Hematocrit 0.35 0.38-0.50 WBC Count 24.0 5.00-10.00 x 9/L Neutrophil 0.73 0.40-0.60 NormalLymphocyte 0.20 0.02-0.08 Monocyte 0.01 0.00-0.04 Eosinophil 0.01 0.00-0.01 Normal

ROUTINE URINALYSIS

April 14, 2007

EXAMINATION MADE

RESULT NORMAL VALUES

CLINICAL SIGNIFICANCE

Color yellow Amber yellow NormalCharacter turbid Clear InfectionReaction/pH 6.0-Acidic 4.8-8.0 NormalSpecific gravity 1.020 1.015-1.025 NormalProtein +++ (-) InfectionSugar (-) (-) NormalRed blood cells 0-3 hpf (-) InfectionPus cells Many(>100/

hpf)(-) Infection

Epithelial cells Few (-) InfectionAmorphous phosphates

Few (-) Infection

Bacteria Many Infection

VII. DRUG STUDY

Parenteral Medication:

Cefuroxime (kefox) 200 mg IV q8 ANST (-)

Drug Classification: CephalosporinContent: Cefuroxime Sodium

INDICATION

DOSAGE

CONTRAINDICATION

SPECIAL PRECAUTION

ADVERSE REACTION

DRUG INTERACTION

Respiratory tract, ENT, urinary tract, skin and soft tissue, O and G, bone and joint infections, surgical prophylaxis.

Children and infant: 300-100 mg/kg/ay in 3 to 4 divided doses.

Hypersensitivity to cephalosporin. Acute porphyria.

Pronounced renal insufficiency. Patients receiving concurrent treatment with diuretics e.g. furosemide and aminoglycosides. Anaphylactic reactions to penicillin.

Glossitis, N/V, diarrhea, gastric pyrosis, abdominal pain, very seldom, urticaria or cutaneous rash, pruritus and arthralgia.

Cross allergy of penicillin

VIII. NURSING CARE PLAN

1.) Nsg. Dx: Urinary Elimination, altered related to Urinary Tract Infection.

DATA/CUES NURSING DIAGNOSIS

PLANNING NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:“Umiiyak siya kapag umiihi” as verbalized by the Grand mother.

Objective:

Urinary Elimination, altered related to Urinary Tract Infection.

After 4 hours of nursing intervention, the patient will achieve normal elimination pattern.

INDEPENDENT

NURSING FUNCTION:

* Assess causative or contributing factors.

* To detect urinary

After 4 hours of nursing intervention, goal is met. Patient achieved normal elimination

Urgency * Inspect stoma for edema, scaring, presence of congealed mucus.

* Review drug regimen (note use of drug which are nephrotoxic)

* Note age/sex of patient.

* Review lab tests.

* Determine patient’s previous pattern of elimination.

* Palpate bladder.

* Determine patient’s usual daily intake.

* Encourage fluid intake including cranberry juice.

* Assist in developing toileting routines as appropriate.

* Monitor medication regimen and antimicrobial

diversion.

* Some drugs may result in urinary retention.

* UTI are more prevalent in women and older men.

* To detect hyperparathyroidism, changes in Renal function.

* To assess degree of interference.

* To assess retention.

* To assess condition of skin and mucous membranes.

* To help maintain renal function, prevent infection and formation of urinary stones.

* To help achieve regular urination pattern.

* To identify patient’s response in treatment.

* To discourage

pattern.

s.

* Maintain acidic environment of the bladder by use of agents such as vitamin C.

* Keep diaper area clean and dry.

* Encourage significant others to participate in routine of care.

* Recommend avoidance of gas forming foods or medications that produce strong odor.

bacterial growth when appropriate.

* To prevent rash formation, and to emphasize the importance of reducing risk of infection or skin breakdown.

* To recognize complication, necessitating medical intervention.

* To promote odor control.

2.) Nsg. Dx: Hyperthermia related to increased metabolic rate, due to illness or trauma.

DATA/CUES NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

Objective:* Temperature: 38.3 C

Hyperthermia related to increased metabolic rate, due to illness or trauma.

After 8 hours of Nursing Intervention, patient will

INDEPENDENT NURSING

FUNCTION:

* Identify underlying cause.

After 8 hours of nursing intervention, goal is met. The patient

* flushed skin, warm to touch.

maintain core temperature within normal range.

* Note age of patient.

* Monitor core temperature (rectal and tympanic temperature most closely approximate core temperature.

* Assess neurologic response.

* Monitor Heart Rate and Rhythm.

* Monitor respiration

* Monitor/record all sources of fluid loss such as urine, or other insensible losses.

* Note presence or absence of sweating.

* Provide cool environment, sponge baths.

* Maintain bed rest.

DEPENDENT

* Very young children are at particular risk for permanent neurologic damage.

* To evaluate ranges of temperature.

* To note level of consciousness.

* Cardiac rate and ECG changes occur due to electrolyte imbalance.

* Hyperventilation may initially be present.

* Oliguria or Renal failure may occur due to hypotension.

* Body attempts to increase heat loss.

* To promote surface cooling.

* To reduce metabolic demands or oxygen consumption.

maintained his core temperature within normal range of 36.4C.

NURSING FUNCTION:

* Administer Antipyretics: Paracetamol (Calpol) 1.2 mL, TID. As ordered

* Administer Antibiotics:Cefuroxime (kefox) 200 mg IV q8 ANST (-). As ordered.

* Administer replacement Fluids and electrolytes: D5 0.3 Na Cl 500cc x 27 ugtts/min. As ordered.

* For Fever.

* For Infection.

* To support circulating volume and tissue perfusion.

IX. EVALUATION

Prognosis3.) Generally good in uncomplicated cases.4.) There is a tendency for recurrent infection.5.) Children with obstructive lesions of the urinary tract and those with

severe vesicoureteral reflux are at the highest risk for kidney disease.

Health Education1.) Long term therapy is often prescribed to prevent recurrence of

urinary tract infections. Schedules or prolonged therapy vary for several months to continuous prophylaxis.

2.) The child should be kept under continued medical surveillance because of possibility of disease recurrence.

a. Emphasis should be placed on the fact that even though this disease may have few symptoms, it can lead to very serious, permanent disability.

b. Periodic urine cultures are indicated for two years following the acute infection.

Prevention

1.) Spread of bacteria from the anal and vaginal areas to the urethra can be minimized in female children by cleansing the perineal area from the urethra back toward the anus.

2.) Bubble baths should not be used because of the bladder irritant effect of these solutions.

3.) Encourage adequate fluid intake, especially water.4.) Acidify the urine with juices (e.g. cranberry juice).5.) Encourage the child to void frequently and to empty the bladder

completely with each voiding.6.) Wearing cotton underpants7.) Taking showers versus baths.8.) Avoiding wearing pantyhose with slacks.9.) Washing the perineal area before intercourse and voiding immediately

after.