AKLAN STATE UNIVERSITY

Bachelor of Science in Nursing

Banga, Aklan

OBSTETRICAL ASSESSMENT

I. VITAL INFORMATION:

NAME: K.T
AGE: 18
SEX: F
ADDRESS: Tamalagon, Tangalan, Aklan
RELIGIOUS AFFILIATION: Roman Catholic
ALLERGIES: chicken
DATE OF DELIVERY: N/A
TIME OF DELIVERY: N/A
EDUCATIONAL ATTAINMENT: Senior High School Graduate
CIVIL STATUS: SINGLE
DATE & TIME ADMITTED: N/A
PHYSICIAN’S INITIAL: K.I
CHIEF COMPLAINT:
IMPRESSION/DIAGNOSIS:

INFORMANT: Patient herself

RELATIONSHIP TO PATIENT: Patient herself

II. OBSTETRICAL HISTORY

G1P1T1P0A0L0 LMP: January 25, 2019 EDC: November 1,

2019

MENARCHE: April 2012

CYCLE: 28 days
DURATION: 6 days
NO. OF PADS PER DAY: maximum of 4 pads a day

TYPES OF DELIVERY:
NSVD _______ CESAREAN SECTION _______ OTHERS _______

EPISIOTOMY: YES _______ NO _______

TYPE OF INCISION:
MEDIOLATERAL: RIGHT ______ LEFT ______
MEDIAN:

PREVIOUS MEDICAL EXPERIENCE: YES _______ NO _______

DATE:
REASON FOR HOSPITALIZATION: N/A

DATE OF LAST CONSULTATION WHILE PREGNANT: October 16, 2019

DID YOU RECEIVE ANY HEALTH TEACHINGS REGARDING?
LABOR ______ POSTPARTUM ______DELIVERY ______NEWBORN CARE ______
DOES SHE DO ANY READING? YES _______ NO _______
IF YES, SPECIFY WHAT MATERIALS ARE BEING READ:
The patient utilized books such as guides to healthy pregnancy, nine months of practical
tips and useful advices, and a child is born etc.
ANY COMPLICATIONS DURING THIS PREGNANCY/PREVIOUS PREGNANCY:
The patient had experience a cord coil and urinary tract infection during pregnancy.

MEDICATIONS TAKEN DURING PREGNANCY:

- Mosvit Elite #30

1 Cap/day
- Sorbifer Durules #30
1 Tab/day
- Calvit Gold #30
1 Cap/day
- Onima #30
1 Tab/day
- Ferrous Sulphate + Folic Acid
1 Tab/day
- Cefuroxime (Zinacef) #21
3x a day for 7 days

FAMILY PLANNING: N/A

HAS FAMILY PLANNING BEEN PRACTICED? YES _______ NO _______
METHOD OF CONTRACEPTION USED: N/A
IF NO, SIGNIFIES WILLINGNESS TO PRACTICE FAMILY PLANNING?
The patient is willing to practice family planning after current pregnancy.
METHOD: N/A

PREVIOUS PREGNANCY

LOCATION TYPE OF COMPLICATIONS DATE

DELIVERY
N/A N/A N/A N/A
N/A N/A N/A N/A

III. CLINICAL ASSESSMENT

A. NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

KT is an 18-year old female for whom prenatal visits are needed to
monitor the condition of both the baby and her. On her last appointment to
the doctor they found out that part of the umbilical cord was seen overlying
the fetal neck region. According to the doctor, the problem occurred
because the baby had an excessive movements inside the amniotic sac
due to small size. The patient is under observation up until the estimated
date of her labor since she had lesser possibility to have a normal
delivery.

A. USUAL HEALTH STATUS

The patient is anemic, and often experiences UTI.

B. CHRONOLOGIC STORY
“Kung nagutom abi ako hay gusto ko permi may sawsawan ag ga
ininom akot sofdrinks” as verbalize by the patient. The patient had a
Urinary tract infection which means an infection in any part of your
urinary system your kidneys, ureters, bladder and urethra. Located
at the lower urinary tract (the bladder and Urethra). Also the patient
felt lower back and abdominal spasm, she can feel pain radiating
 around her pelvic area and when urinating she said “masakit ako
mag ihi, bukon man gid masakit nga mayad pero kulay yellow ang
ihi” as verbalize by the patient.

C. RELEVANT FAMILY HISTORY

The patient’s grandfather and grandmother had hypertension at her
father’s side. While on the other side her grandmother had asthma.

D. DISABILITY
N/A

2. FAMILY HISTORY OF ILLNESS

GENOGRAM

LEGENDS:

o - Male with Hypertension - Female with Hypertension

- Male with - Female with Asthma

- Female - Pregnant Women (patient)

3. PATIENT’S EXPECTATIONS
 WHAT SHE EXPECTS TO OCCUR DURING HOSPITALIZATION
“Syempre, indi man gid ako mag expect it grabe dahil sayran ko man
nga public hospital kaya basta maaccommodate eang nanda ako it
mayad during it akon nga hospitalization ag maging successful ang
delivery”, as verbalized by the patient.

 REGARDING NURSING CARE

 The patient expects proper care and management.

4. PATTERNS OF FUNCTIONING

A. BREATHING PATTERN
REPIRATORY PROBLEM: Difficulty of breathing
USUAL REMEDY: Side-lying position
MANNER OF BREATHING: Regular breathing

B. CIRCULATION
USUAL BP: 90/80
HISTORY OF CHEST PAIN, PALPITATION, COLDNESS OF
EXTREMITIES: She often experience palpitations
PRESENCE OF EDEMATOUS AREA: Right and left foot

C. SLEEPING PATTERN
USUAL BEDTIME: 11 pm
HOURS OF SLEEP: 7 hours
NAP HABITS: The patient takes a nap right after she ate her lunch
PROBLEMS REGARDING SLEEP: Disturbed sleeping pattern
USUAL REMEDY: Putting eye mask
NO. OF PILLOWS: 3 pillows, at both sides and one at my head
BEDTIME RITUALS: half bath, praying

D. EATING PATTERNS
APPETITE WHILE PREGNANT: Good appetite
DIET WHILE PREGNANT: Less carbs and low fat milk.
WEIGHT GAIN: The patient gained 6 kg during her pregnancy

USUAL FOOD TIME

Breakfast 2 cups of rice, 1 fried fish 8:00 AM
Lunch 2 cups of rice, sinigang 11:30 AM
Snacks bread 2 pcs and milk 3:00 PM
Dinner 2 cups of rice, adobo 7:00 PM

FOOD LIKES: Sweets

FOOD DISLIKES: Guyabano
FOOD PREFERENCES: Savory and sweet foods

E. ELIMINATION PATTERN
BOWEL MOVEMENT: 2x a day
CONSTIPATION: Hard stool
USUAL REMEDY: increased water intake 10-16 glasses a day
BLADDER IRREGULARITIES: The patient experienced urinary
frequency and painful urination

F. REST AND ACTIVITIES

ACTIVITY DURING DURATION OF PREGNANCY: Walking for 20
minutes a day and cooking.
REST PERIOD DURING PREGNANCY: 4 hours a day
EXERCISE DONE ON THE:
FIRST TRIMESTER: Walking
SECOND TRIMESTER: Walking
THIRD TRIMESTER: Walking

G. HEALTH SUPERVISION (ANY PRENATAL CONSULTATION DONE

AND WITH WHOM)
 a. 1 month to 7 months – every month by Dr. KI
b. 7 – 8 months – every 2 weeks by Dr. KI
c. 8 – 9 months – every week by Dr. KI

5. CLINICAL INSPECTION

A. VITAL SIGNS (October 21, 2019)

Temperature: 36.5°c
Respiration Rate: 22 bpm
Pulse Rate: 90 bpm
Blood Pressure: 110/80 mmHg

B. HEIGHT: 152 cm
WEIGHT: 51 kg

C. GENERAL APPERANCE

Assessment Procedure Normal Findings Abnormal

SKIN
Inspect the general skin
coloration.
Assess for skin integrity.
Inspect for lesions and
bruises.
Palpate skin to assess
texture.
Palpate to assess thickness.
Palpate to assess moisture.
Palpate to assess
temperature.
Palpate to assess mobility
and turgor.
Palpate to detect edema
SCALP AND HAIR
Inspect the scalp and hair for
general color condition.
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair.
Findings
Inspection reveals evenly colored
skin tone and increased
vascularity; however, the patient
had darkened portions (chloasma)
on axilla and neck.
The patient’s skin was intact and
there are no reddened areas.
Her skin was smooth, without
lesions. There were stretch marks
on her abdomen and some moles
on different parts of the body. No
lesions and bruises.
The patient’s skin was smooth and
even.
Skin was normally thin.
Skin surfaces of the patient were
partly dry and moisten.
Her skin was normally a warm
temperature.
Her skin was mobile, with elasticity
and returned to original shape
quickly after being pinched. Also,
the recoil was immediate.
The patient’s skin rebounded and
does not remain indented when
pressure was released after being
pressed.
The patient had a natural black
hair, smooth and firm, somewhat
elastic. Her scalp was clean and
dry.
There were adequate amounts of
fine hair that cover her entire body
except for the soles, palms, lips,

NAILS
Inspect nail grooming and
cleanliness.
Inspect nail color.
Inspect shape of nails.
Palpate the nails to assess
texture.
Palpate to assess texture
and consistency.
Test capillary refill in nail
beds.
HEAD AND FACE
Inspect the head.
Palpate the head.
Inspect the face.
Palpate the temporal artery.
Palpate the
temporomandibular joint.
NECK
Inspect the neck.
Inspect the movement of the
neck structures.
Inspect range of motion.
Palpate the trachea.
Palpate the thyroid gland.
Palpate the lymph nodes.
and nipples. The patient was also
removing her axillary hair and
shaving her genital hair.
The nails of the patient were clean.
Her nails had pink tones.
The patient’s nails were square
and there was a 160-degree angle
(no clubbing) between the nail
base and the skin.
Her nails were hard and basically
immobile.
Her nails were smooth and firm;
nail plate was firmly attached to
her nail bed.
Her pink tones returned
immediately from blanched nail
beds when pressure was released.
The patient’s head was symmetric,
round, erect, and in midline. Also, it
was appropriately related to her
body size. There were no lesions
visible.
The head was normally hard and
smooth, without any lesions.
Her face was symmetric with a
round appearance. There were no
abnormal movements noted.
Her temporal artery was elastic
and not tender.
There was no swelling, tenderness
or crepitation with movement. Her
mouth opens and closes fully.
Also, her lower jaw laterally moves
1-2cm each in each direction.
The patient’s neck was symmetric,
with her head centered and without
bulging masses.
The thyroid cartilage and cricoid
cartilage move upward
symmetrically as she swallowed.
Her neck movement was smooth
and controlled with 45-degree
flexion, 55-degree extension, 40-
degree lateral abduction, and 70-
degree rotation.
Her trachea is in midline.
The landmarks (hyoid bone,
thyroid cartilage, cricoid cartilage)
were positioned midline.
There was no swelling or
enlargement and no tenderness on
the preauricular, tonsillar,

EYES
Test distant visual acuity.
Test visual fields for gross
peripheral vision.
(confrontation test)
Test for corneal light reflex.
Perform cover test.
Perform cardinal fields of
gaze test.
Inspect the eyelids and
eyelashes.
Observe the position and
alignment of the eyeball in
the eye socket.
Inspect the bulbar
conjunctiva and sclera.
Inspect and palpate the
lacrimal apparatus.
Inspect the cornea and lens.
submandibular, submental,
superficial cervical, posterior
cervical, deep cervical, and
supraclavicular nodes.
The patient had a normal vision
with a distant visual acuity of
20/20.
With the test, the patient could see
the examiner’s finger at the same
time the examiner sees it. She had
normal visual field degrees.
The reflection of light on the
corneas was on the exact same
spot on each eye; this indicates
that the patient had a parallel
alignment.
The uncovered eye of the patient
remained fixed straight ahead.
Then the covered eye also
remained straight ahead after
being uncovered. There were no
deviation in alignment and eye
movements.
Her eye movement was smooth
and symmetric throughout all six
directions.
The upper lid margin was between
the upper margin of the iris and the
upper margin of the pupil. The
lower lid margin was rested on the
lower border of the iris. There was
no white sclera seen above or
below the iris. Also, her upper and
lower lids close easily and meet
completely when closed. Then, her
eyelashes were evenly distributed
and curved outward along the lid
margins.
The patient’s eyeballs were
symmetrically aligned in the
sockets without protruding or
sinking.
The bulbar conjunctiva of the
patient was clear, moist, and
smooth. Her sclera was white.
There was no swelling or redness
appeared over the areas of the
lacrimal gland. The puncta was
visible without swelling or redness
and was turned slightly toward the
eye. Upon palpation of the
nasolacrimal duct, there was no
drainage noted from the puncta.
Her cornea was transparent, with
no opacities. With oblique view, it

Inspect the iris and the pupil.
Test pupillary reaction to
light.
Test the accommodation of
the pupils.
EARS
Inspect the auricle, tragus,
and lobule.
Inspect the external auditory
canal.
Perform the whisper test.
Perform the Romberg test.
MOUTH
Inspect the lips.
Inspect the teeth and gums.
Inspect the tongue.
Note for odor.
Inspect the uvula and tonsils.
NOSE
Inspect and palpate the
external nose.
showed a smooth and overall
moist surface; the lens was free of
opacities.
Her iris was round, flat and evenly
colored. Her pupis were equal in
size and round with a regular
border, centered in the iris.
Her pupils constricted.
Her pupils constricted and her
eyes converged when focusing on
a near object.
The patient’s ears were equal in
size bilaterally. Her earlobes were
attached to adjacent skin. The skin
was smooth, with no lesions,
lumps, or nodules. The color was
consistent with facial color. Her
auricle, tragus, and lobule were not
tender.
There was a small amount of
odorless cerumen (earwax)
present. It was pale yellow and
seemed to be moist.
The patient was able to repeat the
word that the examiner had
whispered.
The patient was able to maintain
her position for 20 seconds without
swaying or with minimal swaying.
Her lips were smooth and moist
without lesions or swelling.
The patient had 32 teeth with
smooth surfaces and edges. There
were no decayed areas and no
missing teeth.
Her jaws were aligned with no
deviation seen with biting down.
Also, her gums were pink, moist,
and firm with tight margins to the
tooth. There were no lesions or
masses.
Her tongue were pink, moist, and
in a moderate size.
There was no unusual or foul odor
noted.
Her uvula hanged freely in the
midline with no redness. Her
tonsils were present, pink and
symmetric.
The color of her nose was the
same with the rest of her face. Her
nasal structure was smooth and

Check patency of airflow
through the nostrils.
Inspect the internal nose.
BREASTS
Inspect the size and
symmetry.
Inspect color and texture.
Inspect the areolas.
Inspect the nipples.
Inspect for retraction or
dimpling.
Palpate for tenderness and
temperature.
Inspect and palpate the
axillae.
POSTERIOR THORAX
Inspect the configuration.
Observe use of accessory
muscles.
Auscultate for breath sounds.
Observe quality and pattern
of respiration.
ANTERIOR THORAX
Inspect for shape and
configuration.
symmetric. The patient reported
swelling of her nose which was
normal in pregnancy.
The patient was able to sniff
through each nostril while other
was occluded.
The nasal mucosa of the patient
was dark pink, moist, and free of
exudate. Her septum was intact
and free of ulcers or perforations.
The patient’s breasts were
somewhat round. And one breast
was larger than the other.
Her breasts had the same color
with her skin tone. The texture was
smooth, with no edema.
Her areolas were dark brown in
color and they were round.
Her nipples were nearly equal
bilaterally in size, were in the same
location on each breast, and were
everted.
While raising her arms, the
patient’s breasts rose
symmetrically, with no sign of
dimpling or retraction. And when
she leaned forward, her breasts
hang freely and symmetrically.
The patient’s breasts were slightly
swollen and tender to touch. The
patient reported that her breasts
felt heavier and fuller.
There was no rash or infection
noted. And there were no palpable
nodes in the central area of the
axillae.
The patient’s scapulae were
symmetric and nonprotruding. Her
shoulders and scapulae were at
equal horizontal positions.
The patient slightly used accessory
muscles to assist breathing during
the assessment.
Normal and clear breath sounds
were heard. There were no
wheezing or crackles auscultated.
Also, her respiration was relaxed
and quiet. They were of a regular
rhythm and normal depth at 22
breaths per minute.
The antero posterior diameter of
the patient was less than the
transverse diameter.
Inspect the position of the
sternum.
Inspect slope of ribs.
Inspect intercostal spaces.
HEART
Auscultate the heart rate and
rhythm.
ARMS
Observe arm size and
venous pattern.
Observe coloration of the
hands and arms.
Palpate the client’s fingers,
hands, and arms, and note
the temperature.
Palpate to assess capillary
refill time.
ABDOMEN
Note the vascularity of the
abdominal skin.
Note any striae.
Inspect for scars.
Assess for lesions and
rashes.
Inspect abdominal and
umbilical contour.
Percuss and auscultate for
bowel sounds.
GENITALIA
Assess for presence of
lesions, tenderness or
masses.
Assess for swelling or
bulging.
Assess for vaginal
discharges.
Assess for urinary status.
Assess for hemorrhoids.
LOWER EXTREMITIES
Observe the client’s posture.
Observe Gait.
Her sternum was positioned at the
midline and straight.
Her ribs sloped downward with
symmetric intercostal spaces.
There were no retractions or
bulging of intercostal spaces
noted.
The heart of the patient was 90
beats/min, with a regular rhythm.
Her blood pressure was 110/70
mmHg.
Her arms were bilaterally
symmetric with minimal variation in
size and shape. There was no
edema observed.
The patient’s color of the hands
and arms was the same bilaterally.
Her skin was warm to touch
bilaterally from fingertips to upper
arms.
Her capillary beds refilled in less
than 2 seconds.
There were scattered fine veins
visible. There was an increased in
vascularity.
There was presence of striae in the
abdomen (brown in color).
There were no scars present.
Her abdomen was free of lesions
or rashes.
The patient had a generalized
protuberant abdomen and a
protuberant umbilicus.
Percussible tympany over the
intestines and dullness over the
uterus. Also, fetal heart beat could
be heard on auscultation at the
lower left quadrant.
There were no lesions present.
Also, no tenderness of masses.
The patient was not experiencing
hemorrhoids.
The patient’s posture was erect.
Evenly distributed weight. Patient’s
able to stand on heels and toe.

Assess for the risk of falling
backward in the older or
handicapped client.
Inspect and palpate the TMJ.
Test ROM.
Inspect the lower extremities
Toes on point straight ahead.
Equal on both sides.
Client did not fall backward.
Snapping and clicking was felt and
heard.
The patient’s ROM was normal
and in full range.
Edema was seen on patient’s feet.

GENERAL APPRAISAL:

BODY BUILT: The patient had an ectomorph body built.

SPEECH: She was able to narrate or share information about her and she
answered the questions asked naturally.
LANGUAGE: Akeanon
HEARING: The patient had a good hearing acuity.
MENTAL STATUS: The patient was conscious at the time of the assessment;
she listens attentively and very oriented about her situation. Also, she shared her
perceptions regarding her experience with pregnancy.
EMOTIONAL STATUS: She was cooperative throughout the assessment and
radiated a light mood together with the examiners. She was smiling and gave
genuine expressions based on the situation on the topic.

HANDICAPS & LIMITATIONS:

1. SOCIAL The patient sometimes experienced stress due to the
environment, and showed mood swings to people around her.
2. PHYSICAL The patient didn’t need assistance with ADL’s.

IV. LABORATORY & DIAGNOSTIC PROCEDURES

1. CLINICAL CHEMISTRY:
NAME OF EXAMINATION: Hemoglobin A1C (HbA1c) Test
DEFINITION: This test measures the amount of blood sugar (glucose)
attached to hemoglobin.
PURPOSE: An HbA1c test may be used for diabetes or prediabetes in adults.
RESULTS:
DATE: June 27, 2019

COMPONENTS RESULTS NORMAL SIGNIFICANCE

VALUES
HbA1C 4.6 % 4.5-6.4 The amount of blood sugar is
below 5.7% which is normal.

2. NAME OF EXAMINATION: URINALYSIS

DEFINITION: Urinalysis a test of your urine, it involves checking the
appearance, concentration and content of urine.
PURPOSE: to detect and manage a wide range of disorders, such
as urinary tract infections, kidney disease and diabetes
RESULTS:
DATE: 6/27/19

RESULT NORMAL SIGNIFICANCE

Color: Straw Amber Dehydrated
Transparency: Turbid Clear Presence of protein or excess cellular
 material.
Reaction: 7.0 4.5-8 Neutral
Specific Gravity: 1.015 1.005-1.025 Isosthenuric
Sugar: Negative Negative Normal
Albumin: Trace Negative There is albumin in the urine.
Pus cells: ++ (34-51) 0-4 This is an indicative of an infection.
RBC: Occasional 2-4 2 This is an indicative of infection or
irritation of the tissue of the urinary tract.

3. NAME OF EXAMINATION: HEMATOLOGY

DEFINITION: is the study of blood in regards to a person's health or disease.
It includes blood, blood-forming organs, and the proteins involved in bleeding
and clotting.
PURPOSE: can be used to indicate, diagnose, and evaluate many conditions,
including infection, inflammation, and anemia.
RESULTS:
DATE: 6/27/19

COMPONENTS RESULTS NORMAL VALUES SIGNIFICANCE

Hemoglobin 116 g/L F: 120 - 160 g/l Low hemoglobin is termed
anemia or the person is
describe as anemic.
Hematocrit 0.34 Vol. Fr. F: 0.37 - 0.43 Vol. Low hematocrit maybe sign
Fr. of vitamin b-12 deficiency.
RBC Count 3.65 x F: 4.0 – 5.4 x If the number of RBCs is
10^12/L 10^12/L lower than normal, it may
be caused by anemia.
WBC Count 9.0 x 10^9/L F: 4.0 – 10.0^9/L A low white blood cell
count, can result from
conditions such as (vitamin
B-12 deficiency)
Band 0.00 0.02 – 0.05 A low blood level of
Neutrophils neutrophils is a condition
called neutropenia.
Sometimes caused by
vitamin B-12 deficiency
Segmenter 0.83 0.55 – 0.65 Some specific causes of an
Neutrophils increased neutrophil count
(neutrophilia) is pregnancy.
Eosinophils 0.02 0.02 – 0.04 Normal
Basophil 0.00 0.00 – 0.01 Normal
Lymphocytes 0.15 0.25 – 0.35 Low counts can indicate
possible infection or other
significant illness.
Monocytes 0.03 0.03 – 0.06 Normal
Platelet Count Adequate 150 – 450 x 10^9/L Normal

4. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS:

NAME OF EXAMINATION: Obstetrical Ultrasonography
DEFINITION: In pregnancy, in which sound waves are used to create real
time visual images of the developing embryo or fetus in its mother’s uterus
(womb).
PURPOSE: To screen for and diagnose birth defects and/or hereditary
conditions.
DATE: October 08, 2019
IMPRESSION
  Single, live intrauterine pregnancy of about 34 weeks and 5 days
age of gestation
 Cephalic presentation at the time of procedure
 Total amniotic fluid index as of this scanning time = 12 cm
 Grade II, Posterior, high lying placenta
 BPS = 8/8
 Suspicious cord coil, neck

DATE: October 27, 2019

IMPRESSION
 Single live intra-uterine pregnancy of about 27 weeks 4 days sonar
age based on composite measurement
 Cephalic presentation. Normohydramnios.
 Grade 1, Posterior placenta. No praeva.

V. TEXTBOOK DISCUSSION:

A. DIAGNOSIS: Urinary Tract Infection

PATHOPHYSIOLOGY:

Lower UTIs, also known as cystitis, are significantly more prevalent in

women than in men. This is primarily because of anatomic differences, including
shorter urethral length and moist periurethral environment in women. Urinary
tract infections typically start with periurethral contamination by a uropathogen
residing in the gut, followed by colonization of the urethra and, finally, migration
by the flagella and pili of the pathogen to the bladder or kidney. Bacterial
adherence to the uroepithelium is key in the pathogenesis of UTI. Infections
occur when bacterial virulence mechanisms overcome efficient host defense
mechanisms. Upper UTIs, also known as pyelonephritis, develop when
uropathogens ascend to the kidneys by the ureters. Infections can occur when
bacteria bind to a urinary catheter, a kidney, or a bladder stone or when they
are retained in the urinary tract by a physical obstruction. In severe cases of
pyelonephritis, the affected kidney may be enlarged, with raised abscesses on
the surface (as revealed in imaging studies). Staphylococcus aureus
bacteremia or endocarditis can lead to hematogenous seeding of the bacteria to
the kidneys, causing suppurative necrosis or abscess formation within the renal
parenchyma (Sobel 2014). In contrast, gram-negative bacilli rarely cause kidney
infection by the hematogenous route. According to an experimental model of
pyelonephritis, the main renal abnormality reported is the inability to maximally
concentrate the urine (Sobel 2014). This concentration defect occurs early in
the infection and is rapidly reversible with antibiotic therapy. An obstruction can
lead to progressive destruction of the affected kidney and subsequent renal
insufficiency.

B. DEFINITION:
Urinary tract infection (UTI), in humans, inflammation of the renal
system characterized by frequent and painful urination and caused by the
invasion of microorganisms, usually bacteria, into the urethra and bladder.

C. S/Sx FOUND IN THE BOOK

 Burning or pain with urination
 Frequent or urgent urination
 Fever
  Lower abdominal pain
 New wetting episodes or more frequent occurrences
 Side or back pain
 Blood in urine

MANIFESTED BY PATIENT
 Side or back pain
 Burning or pain with urination
 Frequent urgent urination
 Lower abdominal pain

D. SCHEMATIC DIAGRAM

MEDICAL MANAGEMENT: Pregnant women should be treated when

bacteriuria is identified. The choice of antibiotic should address the most
common infecting organisms (i.e., gram-negative gastrointestinal
organisms). The antibiotic should also be safe for the mother and fetus.
Historically, ampicillin has been the drug of choice, but in recent years  E.
coli has become increasingly resistant to ampicillin. Ampicillin resistance is
found in 20 to 30 percent of E. coli cultured from urine in the out-patient
setting. Nitrofurantoin (Macrodantin) is a good choice because of its high
urinary concentration. Alternatively, cephalosporins are well tolerated and
adequately treat the important organisms. Fosfomycin (Monurol) is a new
antibiotic that is taken as a single dose. Sulfonamides can be taken during
the first and second trimesters but, during the third trimester, the use of
sulfonamides carries a risk that the infant will develop kernicterus,
especially preterm infants. Other common antibiotics (e.g.,
fluoroquinolones and tetracyclines) should not be prescribed during
pregnancy because of possible toxic effects on the fetus.

NURSING MANAGEMENT:

HEALTH TEACHINGS: (DISCHARGE PLANNING)

PROBLEM LIST:

1. Urinary tract infection

2. Difficulty breathing
3. Difficulty sleeping
4. Leg cramps

VI. NURSING CARE PLAN (SEE ATTACHED SHEET)

VII. DRUG STUDY (SEE ATTACHED SHEET)