I.

NURSING ASSESSMENT
A.Personal Data
Patient’s Name: Jahzeel Mary D. De Paz
Age: 6 yrs. old
Birth date: November 22, 2003
Address: Youngfield, Tacloban City
Sex: Female
Religion: Baptist
Civil Status: Single
Father: Darrius De Paz (Bombay collector)
Mother: Merrian De Paz (house wife)
Diagnosis: Urinary Tract Infection
Physician: Dr. Ramas
Source of information: Mother
Reliability: 95% (reliable)

Present Illness:

Condition started 3 days prior to interview as an onset of an intermittent Fever, Dysuria

and Incontinence, used TSB as a relief for fever.
Persistence of above symptoms prompted her family to consult a physician.

Past Medical History:

Patient was hospitalized at the age of 6 year old, due to Bilateral Hernia surgery last
May 7, 2010 at EVRMC. Jahzeel again has been hospitalized last june 2, 2010 at City Hospital
due to UTI, associated with fever and cough, and use amoxiclav 7ml 3x a day for 7 days,
paracetamol (vial) for relief. The mother also claimed that her daughter experienced Mumps,
no treatment used. Never experience measles, chicken pox. Jahzeel is a fully immunized child,
as what the mother said.

Family History:

The mother claimed that they have heridofamilial disease, such as arthritis on the
mother side. No known genetic disease on paternal side.

Birth History:

The client is the 2nd sibling of Mr. and Mrs. De Paz, via normal delivery last November
22, 2003 at EVRMC.

Feeding History:

The patient was breastfed from birth until 3 yrs old and 6 months. No alternative milk
used. They started supplementary feeding at an age of 7 moths, such as cerelac, smashed
squash, lugaw etc. take vitamins (tiki-tiki, celine).

Growth and Development:

Complete tooth but defective, at the age of 4 years old the client began to use toilet
with assistance. Her behavior coincides with the normal developmental theories.
Psychosocial History:

Jahzeel is a grade 1 student, with a clean classroom environment. Their house is quite
messy, cemented and has a good ventilation. No nearby lake, river, and open drainage, they
use NAWASA as water supply (not for drinking).

II. Patters of Functioning and Clinical Inspection

Patterns of Functioning Clinical Inspection
1.) Respiratory
- Has a history of cough/colds - RR: 25cpm with a normal frequency
(productive) and rhythm
- No history of asthma, DBT, - No accessory muscle are used in
difficulty of breathing breathing
- Use ventolin or ascof for cough - Mild sneezing (nasal allergy)
relief. - No aids or devices used in
breathing

2.) Circulatory
- No history of Hypertension, - HR/PR: 108bpm as of july 7, 2010
dizziness or fainting, and with regular rhythm
palpitation. - No edema noted
- No chest pain - No discolored parts, cyanosis or
pallor

3.) Food & Fluid Intake

- Usually eat vegetable - BMI: normal
- No difficulty of swallowing - Looks healthy
- Able to masticate food - Good skin turgor
- Eat 3 times a day with a snack at - Moist mucous membrane and lips
9:00am and 3:00pm - Presence of cavity on the lower 2 nd
- Uses mineral water for drinking and 3rd pre-molar
about 8-10 glass per day - No dentures used
- Likes to eat vegetable, meat, fish
and “junkfoods” refuse to eat
“ampalaya”
- No known food allergies

4.) Elimination
- void as needed - Complains for dysuria
- has mild dysuria - Normal bowel sound at leat 15 per
- defecate once a day, preferably minute
morning - No abnormal feces reported
- has a history of diarrhea, and uses - No difficulty of defecating
oresol for relief
 Patterns of Functioning
5.) Regulatory Mechanism
- has a history of intermittent fever,
last july 2, 2010
- use TSB for relief
- no chills
6.) Hygiene
- Take a bath once a day with a half-
bath every evening
- Use shampoo every bath
- Brush her teeth after meal
- No known allergies to
soap/shampoo
- No related belief regarding in
health hygiene
7.) Exercise & Locomotion
- The child walk from the gate of
their school to their classrooms
- Most of the time the child usually
run and dance inside their house
8.) Rest & Sleep
- Sleep at least 8 – 10 hours
- Sleep at past 7:00 pm and rise at
6:00 am
- Take a day nap if no class
- No sleep disturbance, except
waking up for voiding
- No insomnia
- 2 pillows were used during sleep
- Pray before sleeping
9.) Communication & special senses
- right handed
- no eye glasses
- no hearing aids
- use “waray” as a primitive dialect
Clinical Inspection
- Temp: 36.7°C via the left axilla as of
july 2, 2010
- Dry skin with mild perspiration
- No chill
- Intact membranes
- The child is neat
- No lesions
- Even hair distribution
- Moist scalp, no dandruff and
pediculosis
- Normochephalic skull
- Nails were trimmed short and clean
- Mouth is clean, no halitosis or any
unpleasant odor
- ROM: Full
- No movement limitation
- Symmetrical musculature
- No deformities in upper and lower
extremities
- Do not use cane, walker or crouch
- No joint stiffness
- The patient looks alive
- No eye bags noted
- No difficulties of sleeping
- EYES: even distribution of
eyelashes, whitish sclera and pink
conjunctiva, no lacrimation,
PERRLA
- EARS: no tenderness, has cerumen
but not impacted, ears is
proportional to outer canthus of
the eyes
- Nose: has mild discharges no
deviation in turbinates, no epistaxis
 Patterns of Functioning Clinical Inspection
10.) Sensory
- no history of convulsion - time conscious
- no history of consciousness - alert
- no history of epilepsy - able to distinguish blunt and
pointed objects
- able to respond in cold steel

11.) Pain & Discomfort

- presence of dysuria - unable to rate the pain
- cause of UTI

12.) Recreation/Diversion
- watching TV
- dancing, playing toys

13.) Religious Life

- no medallion worn
- she is a Baptist
- no religious belief regarding to
health

14.) Coping Mechanism

- cried when scolded - the patient looks happy
- go to MAMA if there is problem
III. 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.

IV. PATHOPHYSIOLOGY OF UTI

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 Tract

By 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.

Reflux
An 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
Schematic Diagram:

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
- 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 respiratory
2.) gastrointestinal diarrhea
 poor perineal hygiene
 short female urethra
 catheterization
 Inherent defect in the ability of the bladder mucosa to protect it from
microbial infection.
Health Education:

The Child must do, In order to prevent in having a UTI

 Avoid eating Junk foods.

 Drink plenty of water every day.
 Drink cranberry juice daily as this juice seems to help prevent UTIs
 Eat parsley, celery and watermelon
 Urinate when you need to, don’t hold it in.
 Empty your bladder completely when you urinate.
 Always wipe from front to back to prevent fecal matter from entering the urethra.
 Avoid bubble baths.
How can the Mother help her children to prevent UTI?
 Avoid giving your child junk foods.
 Have the child consume at least eight 8-ounce glasses of water per day.
 Avoid giving your child bubble baths.
 Dress your child in loose-fitting clothing (including underpants).
 If you have a girl, teach her to wipe from front to back after she uses the bathroom so
that germs from the rectum aren't wiped into the vagina.
 Some children don't go to the bathroom often enough. If your child does this, teach him
or her to go to the bathroom several times each day.
 If you have an uncircumcised boy, teach him how to wash the foreskin on his penis
regularly.
 Encourage your child to urinate whenever he/she feels the urge. And not to hold urine.
 Holy Infant College
Tacloban City

CASE STUDY
Of
Urinary Tract Infection
UTI/Cystitis

Submitted By:
Arvin Ian C. Peñaflor
Brent Cue Kim Dit
Charisse May Cinco
BSN-3 students

Submitted To:
Ms. Aileen Jane Siao
Instructor