Al Quds university

Facility of health professions

Department of nursing

Adult nursing (2)

Data collection sheet: UTI

Prepared by: St.laith Yaghi

NO.21810333

Prepared to: Mr. Anas Al-amleh

MSN BSN
Biographic Data:
Name of penitent (initials): A.M
Age: 66 years Hospital: alia hospital Ward: surgical ward
Bed:1/2
Admission Date: 24/9/2020
Allergies: Food: unknown Drug: unknown
Diet patient on: regular diet
Informant: the patient file and her daughter

Medical Diagnosis:
UTI (urinary tract infection)
Chief complain: Reason for seeking health care:
Presented to the ER C/O general weakness associated with high grade fever since 5 days and
not improved on oral antibiotics
History of present illness:
Cervical disc problem
Pt has a history of cough and sputum production
And a history of dyspnea which increases with exertion
Other Current health problems:
pt lost her appetite since the admission date
no other health problems arise while her stay at the hospital
Past medical Health History:
DM for almost 10 years now
And HTM for 12 years as her daughter said
Pt is bedridden because of CVA snice 2 years ago
Pt has a history of heart disease as the family said
Past surgical history:
Pt has done a cervical discectomy
No other surgical producers done as the daughter said
Family History:
The pt mother and father both had DM before they died
The pt husband is also deceased
One of her two sons has HTM
The daughter said that her mother has two sons and one daughter, she lives with them and
they all have a good relationship with each other's
Psychosocial History:
the patient has a good relationship with the family, and the community around him as the
daughter said but sometimes, she gets annoyed at the kids playing in the streets for making
loud noises
Environmental History:
The pt living in dura the house is located in an area free of pollution and clean water supply
She lives with her 2 sons and daughter in a 3 bedrooms 2 bathroom and a kitchen house
It’s a quite area they said, they don’t have any factories or other things that can pollute air
Review of system: Physical assessment:
General Appearance:
P.t is well groomed and clean, pt. ht:160cm/wt:115kgs
No signs of distress
Good body build,
Pt had trouble speaking because of the CVA she had
Skin, Hair & Nails:
p.t skin is clean, no lesions or masses, skin is not dry p.t nail appear pinkish and are cut,
blanch or PAP test is done (when nails are pressed, they turn pale but quickly return pink in
less than 3 seconds which indicates good capillary refill), forearms are full of edema
Head and neck:
The shape of her head is symmetrical in proportion to her body.
she has no injuries or lesions in her head
lymph nodes have been palpated and no enlargement found
she can move her neck and head without any difficulties.
Hair:
Pt hair is black with a bit of gray colored ones
Pt hair is Clean not dry
No alopecia p.t hair is not falling of
Eyes:
Her eyes are symmetric, brown in color, no abnormal discharges
pupils are rounded symmetrical and reactive to light
Her eyelashes are short with the hair equally distributed along the edge of the conjunctiva;
she doesn’t use glasses.

Ears:
Her ears are symmetrical in size and proportion with her head, she has good hearing ability as
she responded to what I said sometimes by nodding her head,
Her ears are clean, she has no sign of ear infection, no tinnitus, mass or tenderness, and no
excess secretion.
Nose and sinus:
The pt. nose is symmetric in both nostrils, pinkish and moist, there is no bleeding, no
discharges or swelling, no flaring nose no inflammation, no congestion, she breathing
harshly, sinuses have been percussed and no tenderness.
Mouth and pharynx:
Her lips are moist and smooth, she has no lesions or bleeding, Her gums are pinkish, she has
no sore throat or redness, pt has a complete denture for mandible and maxilla
Neck and nodes:
she has no enlargement in her lymph nodes, no masses or tenderness, No history of tonsillitis
The p.t neck muscles tested against hand resistance.
Respiratory system:
Her respiration rate was 17b/min, she has some difficulty in breathing when she moves a bit,
she has a symmetric chest with no deformities or chest enlargement, she has a history of
coughing and sputum production, Chest moves up and out symmetrically on inspiration,
breaths are heard bilaterally equal. Pt is on O2 therapy 2L, SPO2:90
Cardiovascular system:
pulse rate :125, tachycardia
Bp: 150/87
Capillary refill is good (blanch test done)
Pitting edemas found on both legs
Breast and axillary:
axilla have been palpated for masses (no masses found)
Both breasts are symmetrical
No Tenderness when pressing on both of the breasts or the axilla
Abdomen:
abdomen is checked for any masses,
Umbilica is clean no discharge
abdomen is distended the pt feels a mild pain in the abdomen as she expressed with her face
when I pressed on her abdomen

Eliminations:
Bowel:
The stool color is clay, bowel sounds heard, abdominal distention found.
Urinary:
Pt is with foleys catheter, with a urine output of 500cc at the time I checked and took this
case study
Diet and Nutrient:
Pt is on regular diet
Musculoskeletal:
p.t both hands are symmetrical in strength
No fracture
Pt cant move her lower body part
p.t has help preforming all of ger daily activities
Neurological:
Pt GSC 10/15 with L.O.C
The pt. was not fully alert, conscious and oriented to the person she is speaking with
And to the place she is in also to the time of the day
at the end of the assessment she started getting annoyed and her mood suddenly changed
Eyes pupils reacted to light
She obeyed my commands as like when I said raise your right hand, she raised it without any
confusion
she has good senses
at the start of the assessment i poured a bit of alcohol on my hands and asked her dose she
smell any weird smell in the room and she said yes which indicates her good sense of smell
and I didn’t have to raise my voice while talking to her which indicates good hearing sense
INTRAVENOUS THERAPY GIVEN TO THE PATIENT:
Type of IVF Amount Reason for IVF
n/s 1000cc To prevent
dehydration

SPICAIL DIAGNOSTIC TEST DONE FOR THE PATIENT:

 Urine cx done
 ECG done as a routine test.

Others: (CBC, KFT, LFT……. ETC):

1-CBC:

LAP RESULT NORMAL INTERPERTATION

RANGE
HCT 36.64 40%-52%
HB% 11.51 11.5-15 grams/dL Normal
MCH 28.50 27-31 pg/ml Normal
PLTS 173.1 150-400 x10^3/ul Normal
RBC 4.038 4.6-6.2 x10^6/ul Normal
WBC 16.820 5.0-10.0 x1o^3 u/l Indication of infection
MCV 90.73 82-94 um^3 Normal

2-LFT:

LAP RESULT NORMAL INTERPERTATION

RNGE
SGPT 40 0-45Uu/ml Normal
SGOT 25 0-31U/L Normal
Alk. Phos. 162 u\l 0-270u\l Normal
Total billirubin 0.6 mg\dl 0-1.2mg\dl Normal
3-KFT:
LAP RESULT NORMAL INTERPERTATION
RNGE
BUN 4.9 8-23.4 mg/dl Bad protein intake
CREATININE 0.39 0.5-1.4 mg/dl Bad protein intake
4-S.lyets:
LAP RESULT NORMAL INTERPERTATION
RNGE
NA 145 136-146 Normal
K 3.5 3.5-5.0 Normal
CL 109 98-106 Normal
CRP 185 0-5 Indication for
infection

HBSAG:
LAP RESULT
ELISA NEGITIVE

5-coagulation:
LAP RESULT NORMAL INTERPERTATION
RNGE
PT 15.1 11-14 Normal
PTT 23.7 25.36 SEC Normal
INR 1.25 <1
 Medication sheet
Generic Dose Route Classification ?Why

Trade

Names
Perfalgan 1 gm iv Analgesic Used to treat moderate pain and
Paracetamol 1x3 hyperthermia

Rocephin 1mg iv Anti-biotic To treat the infection

Ceftriaxone 11x

Aspirin 100mg po anti-platlate to keep the blood coagulated

acetylsalicylic 1x2
acid

Clexan 40mg sc anticoagulant helps prevent the formation of blood clots

Enoxaparin 1x1

exforge 160/10mg tap Antihypertensive used to control high blood pressure

1x1

Ratadin 50mg iv H2 blockers. used in treatment of peptic ulcer disease,

gastroesophageal reflux disease, and
1x3
Zollinger–Ellison syndrome
 Pathophysiology of the disease
Pathophysiology

The urinary tract is normally sterile. Uncomplicated UTI involves the urinary bladder in a
host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladder
mucosal invasion, most often by enteric coliform bacteria (eg, Escherichia coli) that inhabit
the periurethral vaginal introitus and ascend into the bladder via the urethra.

In recurrent E coli UTIs, peak colonization rates of the periurethral area 2-3 days prior to the
development of the symptoms of acute cystitis range from 46-90%. During this same period,
asymptomatic bacteriuria rates increase from 7% to 70%.

Because sexual intercourse may promote this migration, cystitis is common in otherwise
healthy young women. Generally, urine is a good culture medium. Factors unfavorable to
bacterial growth include a low pH (5.5 or less), a high concentration of urea, and the presence
of organic acids derived from a diet that includes fruits and protein. Organic acids enhance
acidification of the urine.

Frequent and complete voiding has been associated with a reduction in the incidence of UTI.
Normally, a thin film of urine remains in the bladder after emptying, and any bacteria present
are removed by the mucosal cell production of organic acids.

If the defense mechanisms of the lower urinary tract fail, upper tract or kidney involvement
occurs and is termed pyelonephritis. Host defenses at this level include local leukocyte
phagocytosis and renal production of antibodies that kill bacteria in the presence of
complement.

Nursing diagnoses according to NANDA:

1. Hyperthermia May be related to Inflammation Possibly evidenced by Increase body
temperature above normal range. Flushed skin; warm to touch
2. Acute Pain May be related to Inflammation and infection of the urethra,
bladder, and other urinary tract structures.
3. knowledge deficiency R/T lack of exposure to information about the disease as evidence
by request of information
Nursing Care Plan:

Pt Problem: fever

Nursing Dx: Hyperthermia May be related to Inflammation Possibly evidenced by

Increase body temperature above normal range. Flushed skin; warm to touch.

Pt will maintain core temperature within normal range.

Nursing Interventions Rationale Evaluation

Assess for signs of increased
body temperature.
increased body Goal was met pt temp is
temperature will show a now back to its normal
variety of symptoms such ranges
as sweating, shivering,
headache, warm skin, and
body malaise.

Monitor vital signs, To determine appropriate

especially temperature, as interventions
indicated.

Administer antipyretic To reduce body temp.

drugs as indicated
Pt Problem: acute pain

Nursing Dx: Acute Pain May be related to Inflammation and infection of the urethra, bladder,
and other urinary tract structures.

short term goal: Follow prescribed pharmacological regimen

Long term goal.: report satisfactory pain control at a level less than 3 to 4 on a scale of 0 to 10

Nursing Interventions Rationale Evaluation

Assess client’s description of pain
such as quality, nature and
severity of pain
Pain associated with UTI is Goal was met p.t is relieved
described as burning on from the pain
urination, flank pain,
lower abdominal or
suprapubic pain. While
some clients with recurrent
infection are
asymptomatic. This
information will help in
determining the choice of
intervention.

Encourage increased oral fluid increased hydration helps

intake (2-3 liters if no in flushing the bacteria
contraindications). and toxins.

Instruct to avoid coffee, tea, These food items cause

alcohol, and sodas. irritation to the urinary
system and should be
avoided
Pt Problem: knowledge Deficient

Nursing Dx: knowledge deficiency R/T lack of exposure to information about the disease
as evidence by request of information

short term goal: patient family explains disease state, recognizes need for medications,
and understands treatments.
Long term goal: Patient demonstrates how to incorporate new health regimen into
lifestyle

Nursing Interventions Rationale Evaluation

Assess motivation and
willingness of patient to
learn.
Learning requires energy.
Patients must see a need or
purpose for learning. They
also have the right to
refuse educational services.
Goal was met p.t knows
about the underlying
disease she has

Identify the learner: the some patients especially

patient, family, significant
other, or caregiver.
older adults or the
terminally ill view
themselves as dependent
on the caregiver, therefore
will not allow themselves to
be part of the educational
process.

Determine priority of This is to know what needs

learning needs within the to be discussed especially if
overall care plan. the patient already has a
background about the
situation
Teaching and Instructions given to patient during hospitalization related to his disease
about diet, exercises, life style, managing stress, medications, comfort and rest…etc.

We tell the pt when to seek the care of a health provider as like in You have severe
abdominal pain or a fever. Or you suddenly feel lightheaded or faint.

Also, we explain to the pt the importance of taking your medicine as directed. Contact your
healthcare provider if you think your medicine is not helping or if you have side effects. Tell
him or her if you are allergic to any medicine. Keep a list of the medicines, vitamins, and
herbs you take. Include the amounts, and when and why you take them. Bring the list or the
pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency.

Drink more liquids as directed. Liquids help you stay hydrated and urinate more. This helps
prevent harm to your kidneys. Ask how much liquid to drink each day and which liquids are
best for you.

at foods low in fat. Healthy low-fat foods include fruits, vegetables, whole-grain breads, low-
fat dairy products, beans, lean meats, and fish. These foods are easier to digest and may help
reduce your symptoms.

Summary:
we talked about everything that concerns the p.t from why he came to the hospital to what
should she do when she is out of the hospital
Also, we talked about what the p.t took and what happened to the p.t during hospitalization
period. And gave the p.t some advices about what he should do after discharge.