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.

GORDON’S 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 ½ 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 ½ 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 FINDINGS INTERPRETATION

Appearance and mental status

Body build, height, weight Proportionate according o Normal

lifestyle
Posture and gait, standing, sitting Relaxed, erect posture; Normal
and walking coordinated movements
Overall hygiene and grooming Clean, neat Normal
Body and breath odor No body odor; no breath odor Normal
Facial expression Smiling Normal
Attitude cooperative
Quantity of speech, Understandable, moderate pace,
quality, specific Normal
and organization

Skin
Color Light brown; pinkish Normal
Lips, palms, soles Lighter-colored Normal
Moisture Moist Normal
Temperature 37.3 Normal
 Skin turgor Skin snaps back after 3-4 seconds Normal
Texture smooth Normal

Nails
Fingernail plate shape Convex curature Normal
Color Pink Normal
Capillary refill Returns to pink when pressure is
released 3-4 sec

Hair
Normal
Distribution Evenly distributed
Texture Smooth and straight
Normal
Normal
Skull and Face
Size, shape and symmetry Rounded, smooth skull contour Normal
Facial feature Symmetric facial feature Normal
Facial movements Symmetric facial movements Normal
Eyes
Eyelashes Equally distributed; curved Normal
slightly outward
Eyebrows Hair evenly distributed Normal
Eyelids Skin intact; no discoloration Normal
Conjunctiva Transparent with light pink color Normal
Sclera White color Normal
Cornea Transparent, shiny Normal
Pupils Brown, constricts briskly Normal
Iris Clearly visible Normal

Ears
Ear Canal opening Free of lesions Normal
Nose

Shape, size, color Smooth, symmetric with same Normal

color as the face
Nares Oval, symmetric and without Normal
discharge

Mouth

Lips Pink, moist, symmetric Normal

Gums Slightly pink in color, moist and Normal
tightly fit against each tooth
Moist, slightly rough on dorsal
Tongue surface medium or dull red Normal
Shiny and white of enamel

Teeth Normal
Neck
Symmetric, muscles, alignment of Neck, slightly hyper extended, Normal
trachea without masses or asymmetry
Neck rolls Neck moves free without Normal
discomfort
Thyroid gland Neck moves freely without Normal
discomfort
Trachea Rises freely with swallowing Normal

Thorax and Lungs

Shape and symmetry of the Chest symmetric Normal
 thorax
Spinal alignment Spine vertically aligned Normal
Breathing patterns Quiet, rhythmic, and effortless Normal
respirations
Abdomen

Skin integrity Unblemished skin, uniform color Normal

Symmetry Rounded Normal
Abdominal movements Symmetric movements caused by Normal
respiration
Bowel movements Audible bowel movements Normal
Vascular Absence of arterial bruits Normal
Peritoneal friction rubs Absence of friction rub Normal
Percussion of abdomen Tympany over the stomach,gas- Normal
filled bowel; dullness especially
over the liver and spleen
Palpation of the abdomen No tenderness, reflexed abdomen Normal
with smooth, consistent tension
Not palpable
Bladder Normal
Upper extremities (right and left) Equal pulsation
Radial pulse Intact condition of the skin in Normal
Skin integrity arms, no lesions, no swelling Normal

Lower extremities(right and left)

Symmetry Bilaterally symmetrical and equal Normal
Skin integrity Right and left foot has no lesions Normal
and has no swelling
Skin color Same as the other part of the body 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
 Modifiable factors:
Non-modifiable factors: •Inadequate access to toilet
•AGE – UTI is a prevalent facilities
disease among children and •Avoidance of the urge to void
elderly •Urinary catheterization
• SEX – it has a •Fistula between the intestine
higher incidence rate with the and bladder
female gender •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 Increased WBC Change in
to foreign bodies) subsequent to urine color
pus formation

Cytokine and prostaglandin release

Body induces the action of the cytokines and prostaglandins

Cytokine andprostaglandin release

The body responds Inflammation of the lining

by producing of the urinary tract Irritation of the lining of the urinary tract
physiologic changes
aimed at elevating
body temperature.
Narrowed urine passage
Urethritis Urinary spasm of
and dysuria the bladder
Fever
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 Diagnosis Planning Intervention Evaluation

Subjective: Acute pain After 8 hours of Independent: After 8 hours
“Masakit yung related to nursing -Assess pain, of nursing
pagihi ko.” As biological interventions, noting location, interventions, the
verbalized by the factors such the intensity (scale patient’s pain
patient as patient’s pain of will be
trauma or will be 0 – 10), relieved or
Objective activity of relieved or duration. controlled.
-Facial disease controlled. -Encourage
grimace. process increased fluid
-Restlessness. intake.
V/S taken as -Investigate
follows: report
T: 37.3 of bladder
P: 82 fullness.
R: 19 -Observe for
BP: 120/90 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.

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Hyperthermi After an hour of -Monitor patient’s After an hour of
“Ang sakit ng ulo a related to good nursing temperature; good nursing
ko, tapos nilalagnat increased intervention the noting shaking intervention that
pa ako.” As metabolic patient’s chills. patient’s
verbalized by the rate temperature will - Perform Tepid temperature
patient evidenced by decrease from Sponge Bath decreased to 38.2
increased in 38.2 to 37.8. -Increase fluid
Objective body intake
-weak temperature. -administer
-skin hot to medications as
touched prescribed by
-restlessness doctor
Temp = 38.2

DRUG STUDY

Drug Name Indication Contraindication Nursing Responsibilities

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

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.