SYSTEMS PLUS COLLEGE FOUNDATION

Angeles City
COLLEGE OF NURSING

CASE REPORT

Scenario:

A 5-year-old girl presents with recurrent episodes of dysuria. She has been diagnosed and treated for
multiple episodes of urinary tract infections (UTIs). Review of her past medical history reveals 3 to 5
episodes of UTI within the last year. All were diagnosed clinically, based on the presence of dysuria and
abdominal pain. She drinks a large amount of water during the day due to thirst and wakes up every
night to drink at least 1 cup of water.

On physical examination, the well-appearing girl has normal vital signs for age. respectively. All findings
on the physical examination are normal.

Abdominal radiography documents extensive bilateral nephrocalcinosis

Laboratory Findings

 Blood urea nitrogen 25 mg/dL (8.9 mmol)

 Creatinine 1.0 mg/dL (88.4 μmol/L)
 Sodium 141 mEq/L (141 mmol/L)
 Potassium 3.4 mEq/L (3.4 mmol/L)
 Chloride 115 mEq/L (115 mmol/L)
 Carbon dioxide 18.8 mEq/L
 Calcium 9.3 mg/dL (2.3 mmol/L)
 Phosphate 5.6 mg/dL (1.8 mmol/L)
 Ionized calcium 5.4 mg/dL (1.36 mmol/L)
 Urine specific gravity 1.006 g/mL
 Urine pH 6.5

A 24-hour urine collection for stone evaluation demonstrates normal urinary concentrations of oxalate,
phosphate, and calcium. Serum values for parathyroid hormone and vitamin D are normal. Review of the
laboratory results confirms the diagnosis of UTI.
CASE DIAGNOSIS SCIENTIFIC SHORT-TERM / NURSING RATIONALE EXPECTED
RATIONALE LONG-TERM INTERVENTION OUTCOME

S: Abdominal pain Urinary tract SHORT TERM -Determine and -Aids to evaluate -Patient pain will be
-5 y/o female C/O related to infections note location, site of relieved or
chronic dysuria urinary tract typically occur After 2 hours of duration, intensity obstruction and controlled,
with PMH UTI X infection and when bacteria nursing (0–10 scale), and progress of
3-5 episoses dysuria AEB enter the urinary intervention radiation. calculi -patient is relieved
within a year. Pt Laboratory tract through the patient pain will Document movement. of dysuria to
states large Urinalysis urethra and be eliminated or nonverbal signs Flank pain eliminate bladder
amount of water findings and begin to multiply relieved from such as elevated suggests that retention by
intake during the Radiologic in the bladder. 0/10 or 4/10 pain BP and pulse, stones are in the increased of fluid
day and 1 cup of findins of Although the scale or using restlessness, kidney area, intake.
water at night. bilateral urinary system wong baker pain moaning, thrashing upper ureter.
Has presence of nephrocalcinosi is designed to scale. about. Flank pain
admonial pain s keep out such radiates to back,
and difficulty microscopic LONG-TERM abdomen, groin,
urinating. invaders, these genitalia
O: defenses After 4 hours of because of
sometimes fail. nursing proximity of
Lab results: When that intervention pain nerve plexus
•Blood urea happens, patient pain will and blood
nitrogen 25 bacteria may be controlled and vessels
mg/dL (8.9 mmol) take hold and patient dysuria supplying other
•Creatinine 1.0 grow into a full- will be relieved. areas. Sudden,
mg/dL (88.4 blown infection severe pain may
μmol/L) in the urinary precipitate
•Sodium 141 tract. apprehension,
mEq/L (141 restlessness,
mmol/L) severe anxiety.
•Potassium 3.4
mEq/L (3.4 - Justify and clarify -Provides
mmol/L) cause of pain and opportunity for
•Chloride 115 the need of timely
mEq/L (115 notifying administration of
mmol/L) caregivers of analgesia
•Carbon dioxide changes in pain (helpful in
18.8 mEq/L occurrence and enhancing
•Calcium 9.3 characteristics. patient’s coping
mg/dL (2.3 ability and may
mmol/L) reduce anxiety)
•Phosphate 5.6 and alerts
mg/dL (1.8 caregivers to
mmol/L) possibility of
•Ionized calcium passing of stone
5.4 mg/dL (1.36 and developing
mmol/L) complications.
•Urine specific Sudden
gravity 1.006 cessation of
g/mL pain usually
•Urine pH 6.5 indicates stone
A 24-hour urine passage.
collection for
stone evaluation -Implement - Promotes
demonstrates comfort measures relaxation,
normal urinary (back rub, restful reduces muscle
concentrations of environment). tension, and
oxalate, enhances
phosphate, and coping.
calcium. Serum
values for - Encourage use of - Redirects
parathyroid focused breathing, attention and
hormone and guided imagery, helps in muscle
vitamin D are diversional relaxation.
normal. Review activities.
of the laboratory
results confirms - Assist with - Renal colic can
the diagnosis of frequent be worse in the
UTI. ambulation as supine position.
indicated and Vigorous
increased fluid hydration
intake of at least promotes
3–4 L a day within passing of
cardiac tolerance. stone, prevents
urinary stasis,
and aids in
prevention of
further stone
formation.
-Document reports - Complete
of increased and obstruction of
persistent ureter can cause
abdominal pain. perforation and
extravasation of
urine into
perirenal space.
This represents
an acute
surgical
emergency.