INTRODUTION

• This study focuses on the case of a 7 years old client. For confidentiality purposes, the researcher
opted to replace the name of the patient and just call it as “tetsuya 2”. Tetsuya 2 had been
admitted at the pediatric ward at Ospital of Paranaque on march 19,2019, with the final diagnosis
of (UTI) Urinary tract Infection .
• Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys
(pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra
(urethritis), and prostate (prostatitis). However, in practice, and particularly in children,
differentiating between the sites may be difficult or impossible. Moreover, infection often spreads
from one area to the other. Although urethritis and prostatitis are infections that involve the
urinary tract, the term UTI usually refers to pyelonephritis and cystitis.

• Most cystitis and pyelonephritis are caused by bacteria. The most common nonbacterial
pathogens are fungi (usually candidal species), and, less commonly, mycobacteria, viruses, and
parasites. Nonbacterial pathogens usually affect patients who are immunocompromised; have
diabetes, obstruction, or structural urinary tract abnormalities; or have had recent urinary tract
instrumentation.
• Urinary Tract Infection (276,442). The same top four diseases were recorded last year,
• Urinary tract infections (UTIs) are responsible for nearly 10 million doctor visits each year. n One
in five women will have at least one UTI in her lifetime. Nearly 20 percent of women who have a
UTI will have another, and 30 percent of those will have yet another. Of this last group, 80 percent
will have recurrences. n About 80 to 90 percent of UTIs are caused by a single type of bacteria.
HEALTH HISTORY
A.General History
Patient Name: tetsuya 2
Sex: F
Age: 7 years old
Weight: 35kgs
Birth Date: November 7,2011
Address: barangay, vill tambo city of paranaque
Nationality: Filipino
Civil Status: Child
Religion: Catholic
Date of Admission: March 19,2019
Time of Admission: 9:57pm
B. Chief Complaint
Still epigastric pain / vomiting for 2 weeks
C.History of Present Illness
3 days pre (+) epigastric pain w/ vomiting sought consult to ER, Lab showed UTI was given Mediation.
1 day pte- still w/ vomiting and loss of appetite, hence admission
D.Past History
Admitted due bacterial infection
E.Family History
Born to a G2P2 mother Via NSO, no noted complicated, complete immunization, previously admitted past 2018 to unrecalled bacterial infection
GORDONS
Functional Health Pattern sign and symptoms Nursing Diagnosis Planning Intervention Evaluation
Health Staying in the Infection -Follow the number of -Site of the peripheral There is no
Perception – hospital for a long Risk leukocytes. venous catheter was infection signs.
Health time -Wash hands before and observed about infection -There is no
Management -Having several after touching patients. signs. problem about
Pattern cronic diseases -Be careful about aseptic -The number of leukocytes the number of
-Limiting to 800 cc technique. was followed for three days. leukocytes.
liquid -Be aware of about diet and -Hands were washed. -She finished
-Eating half of the liquid intaken -Patient was encouraged ¾ of meal and
Diet about her diet and liquid drinked 800 cc
intaken. liquid.
Nutritional – Weight: 35 Eating less Follow the weight dairly. The weight was followed There is no
Metabolic -Feeling anorexia from body -Observe signs of dairly. weight loss.
Pattern -Having salt free diet needs malnutrition such as hair -Signs of malnutrition such -She finished
-Eating half of the loss, dry and pale skin, as hair loss, dry and pale ¾ of meal and
Diet weakening of the muscles. skin, weakening of the drinked 800 cc
- -Follow the laboratory muscles was observed. liquid
findings. -The laboratory findings was
-Be aware of about diet and followed for three days.
liquid intaken. -Meals served with
-Try to serve meals with dietician.
dietician which patients -Patients room was kept
like.
-Keep the clean patients
Limiting to 800 cc Liquid - Follow vitals signs 4 hours Vital signs was follwed. Vital signs are
liquid volume intervals. -The weight was followed in normal
- Having dark yellow imbalance -Follow the weight dairly. dairly. values.
urine Check the urine colour and -The laboratory findings was Intake:700cc
- Havin light yellow urine amount. followed for three days. Output:800cc
- Urine colour and amount
was checked dairly.
Elimination Making 2-3 times Record the elimination Intake-output list was Intaken:700cc
Pattern juicy and light times and frequence. made. Output:800cc
yellow stool dairly -Make intaken-output list. -The laboratory findings -There is no
-Limiting to 800 cc -Follow the laboratory was problem about
liquid findings. followed for three days. laboratory
-Bowel sounds: -Listen bowel sounds. -800 cc liquid was drinked. findings
7/mn -Give lint-free diet. -Lint-free diet was given. -Bowel
-Bowel sounds were sounds: 7/mn
listened.
Activity– -Waking up tired Lack of Define priority activities Priority activities defined She felt less
Exercise -Changing clothes individual and make an activity plan such as nutrition, tired.
Pattern and making bad with care due to -Plan activities after meals elimination. -Her mother
help. feeling because of using energy - Bathing was put after helped her for
tired. -Place items accessible lunch making dairly
easily in the activity plan. activities.
-Provide help for activities -Activities which need extra
which need extra energy energy were make together
suc as clothing, bathing
Sleep – Rest Sleeping less due to Sleepnessle Define habits that help Care intervations were Patient’
Pattern treatment and care s patient fall asleep (reading made before patient avarage
practices book, drinking milk and sleeping. sleeping hours
-Avarage sleeping etc.). -Music was helped the dairly:
hours dairly: 5 hours patient fall asleep. 6 hours
-Light and noise was made
minimized in the room.
Cognitive – Lack of information Lack of Determine the patients Diagnosis and treatment She told what
Perceptual about diagnoses and information level of information about that patients receive was diagnosis and
Pattern treatment diagnosis and treatment. questioned. treatment she
-Provide information to the -Information provided to have.
patent with physician the
patient with physician.
Role– Lack of information Anxiety Listen the patient about her Patient told about her
Relationship about hospital laying feelings and thoughts. feelings and thoughts She was
Pattern time worring
LABORATORY EXAM
 MARACH 16,2019 6:60PM

COMPONENTS NORMAL VALUES RESULTS IMPRESSION

HEMOGLOBIN (HGB) 12-15 gms% 15.8 Increase in hgb – increase in water loss

HEMATOCRIT (HCT) 37-47vol% 46.0 Normal hematocrit – normal carriage of

oxygen in blood

WHITE BLOOD COUNT 5,000-10,000 12,800 Increase of wbc – due to infection

STABS 3-5% 2% in

SEGMENTERS 55-65% 79% infection, most likely bacterial

LYPHOCYTES 25-35% 19% They can occur after a cold or another

infection,

PLATELET COUNT 150,000-400,00/cu mm 459,000 It is common to have inc. in platelet count

when you have upper urinary infection
March 20,2019 5:20AM
COMPONENTS NORMAL VALUES RESULTS IMPRESSION

HEMOGLOBIN (HGB) 12-15 gms% 14.6 Normal hgb

HEMATOCRIT (HCT) 37-47vol% 44.0 Normal hematocrit

WHITE BLOOD COUNT 5,000-10,000 11,500 Still increase due to infection

STABS 3-5% 3% Normal

SEGMENTERS 55-65% 66% Still increase due bacterial infection

LYPHOCYTES 25-35% 31% Normal

PLATELET COUNT 150,000-400,00/cu mm 496,000 Increase due bacterial infection

March 16,2019 6;50pm urinalysis
COMPONENTS NORMAL VALUES RESULT IMPRESSION

COLOR STRAW/YELLOW Yellow Normal urine color

TRANSPARENECY CLEAR Slightly cloudy urine may result from infection the presence of blood cells, bacteria

REACTION 4.6-7.6 6.0 Normal PH

SP.GRAVITY 1.018-1.025 1.030 Dehydration due to poor fluid intake, vomiting or diarrhea

SUGAR NEGATIVE Negative Normal since 0not normally present in the urine.

PROTEIN NEGATIVE trace Elevated protein levels are known as proteinuria – infection or problems in kidney

MICROSCOPIC

RED CELL 0-1HPF 1-3 Blood present due to trauma in the urinary system

PUS CELL 0-2HPF 12-15 Increase of excursion on of wbc in urine – due to infection
BATERIA F Few bacteria
EPITHELIAL CELL Moderate Normal
MUSCOUS Moderate normal
March 20, 2019 4;53Pm urinalysis
COMPONENTS NORMAL VALUES RESULT IMPRESSION

COLOR STRAW/YELLOW Lightly yellow Normal urine color

TRANSPARENECY CLEAR Slightly turbid urine may result from infection the presence of blood cells, bacteria

REACTION 4.6-7.6 7.0 Normal PH

SP.GRAVITY 1.018-1.025 1.010 Dehydration due to poor fluid intake, vomiting or diarrhea

SUGAR NEGATIVE Negative Normal since 0not normally present in the urine.

PROTEIN NEGATIVE Plus 1 Elevated protein levels are known as proteinuria – infection or problems in kidney

MICROSCOPIC

RED CELL 0-1HPF 1-3 Blood present due to trauma in the urinary system

PUS CELL 0-2HPF 25-30 Increase of excursion on of wbc in urine – due to infection

BATERIA FEW/PRESENT Few Few bacteria

EPITHELIAL CELL Occasional Normal

MUSCOUS Normal
March 24,2019 5;45pm
COMPONENTS NORMAL VALUES RESULT IMPRESSION

COLOR STRAW/YELLOW Light yellow Normal urine color

TRANSPARENECY CLEAR Slightly turbid urine may result from infection the presence of blood cells, bacteria

REACTION 4.6-7.6 6.5 Normal PH

SP.GRAVITY 1.018-1.025 1.005 Dehydration due to poor fluid intake, vomiting or diarrhea

SUGAR NEGATIVE Negative Normal since 0not normally present in the urine.

PROTEIN NEGATIVE Trace Elevated protein levels are known as proteinuria – infection or problems in kidney

MICROSCOPIC

RED CELL 0-1HPF 1-3 Blood present due to trauma in the urinary system

PUS CELL 0-2HPF 25-30 Increase of excursion on of wbc in urine – due to infection

BATERIA FEW/PRESENT Few Few bacteria

EPITHELIAL CELL occasional Normal

MUSCOUS normal
PATHOPHYSIOLOGY
DRUG STUDY
 Drug Name Action Indication Consideration Side effect Nursing consideration

Ceftriaxone Works by Indicated in Hypersensitive Pain Assess patient’s

inhibiting the patients with neurologic To previoussensitivityreactiont
mucopeptide complications, carditis and cephalosporins, penicillins o penicillin
Genenric synthesis in the arthritis. It is also effective in and Induration orothercephalosphorins.
name: bacterial cellwall. Gram negative infections; related
Ceftriazone The beta-lactam Meningitis, Gonorrhea. It isalso for antibiotics
Moietyof Bone and joint infections, Phlebitis Assess patient forsigns
Ceftriaxone Lower respiratory tract andsymptoms of infection
Brand Name: binds to infections,middle ear infection, beforeandduring
Forgram carboxypeptidases, PID, Septicemia and Urinary Rash thetreatment
endopeptidases, Tractinfections
and
Dosage transpeptidases Diarrhea Obtain C&S beforebeginning
450mg TIVq12 in the bacterial drugtherapy
cytoplasmicmembrane. toidentifyif correcttreatmen
These Thrombocytosis thas beeninitiated.
enzymes are
involved in cell-wall Leucopenia
synthesisand cell division.By Report signs suchas
binding tothese enzymes, Glossitis petechiae,ecchymotic
Ceftriaxone areas,epistaxis or
results in theformation of otherforms
defective cellwalls Respiratorysuperinfections of unexplainedbleeding.
and cell death
Monitorhematologic,electro
lytes, renaland
hepaticfunction.

Assess for possiblesupper

infection:itching fever
 Drug Name Action Indication Consideration Side effect Nursing
consideration
Generic name dopamine antagonist that For the treatment of Metoclopramide is Constipation Instruct to take as
Metoclopramide acts by increasing gastroesophageal reflux contraindicated in directed may dilute syrup
sensitivity to disease (GERD) patients with pheochro- Diarrhea in water, juice or
acetylcholine; mocytoma because the carbonated drink
Brand Name resultsincrease motility of drugmay cause a Drowsiness
the upper GI tract and hypertensive crisis,
Dosage relaxation of pyloric probably due to release Fatigue Advise that drug
7mg/IV sphincter and duodenal of catecholamines from increases movements or
bulb the tumor.Such involuntary movements contractions
Classification hypertensive crises may of the limbs
gastrointestinal be controlled by phen-
stimulant tolamine.-

Metoclopramide is
contraindicated in
patients with known
sensitivity or intolerance
to thedrug.
 Drug Name Action Indication Consideration Side effect Nursing
consideration
Generic Name Cause analgesia by Symptomatic relief of Use cautiously in Fever Use liquid form for
Paracetamol inhibiting CNS pain and fever patients with children andpatients
prostaglandin longterm alcohol use Nausea or Vomiting who have
Brand synthesis. because difficultyswallowing
Name therapeuticdoses allergic skin reaction
Tylenol cause hepatotoxicity Advise patient that
in thesepatients. Gastric /Mouth Ulcer drug is only forshort
Classification term use and to
Antipyretic Hematologic: Anemia consult thephysician if
hemolytic giving to children
Dosage anemia,neutropenia, Fatigue forlonger than 5 days
350mg IV Q4 leucopenia, or adults forlonger
pancytopenia. than 10 day

Hepatic: Jaundice Warn patient that

high doses
Metabolic: orunsupervised long
Hypoglycemia term use cancause
liver damage
Skin: rash, urticaria.
NURSING CARE PLAN
• IX. COURSE IN THE WARD
• On March19,2019 Patient Tetsuya2 Admitted at the pediatric ward. Requested to get CBC.
The patients Vital sign are taken and record as follows T= 36, RR =24Cpm, CR=92 Bpm, weight
35kg. The patient will be hooked to IV Fluid D5 0.9 vacl 1Lx 75cc/hr at the right arm. Curent
medication Dicyclorine, cotrimoxcirole, anetoclopromide. Diet DAT, Diagnostic CBC and urinaly.
• Given medication ceftriaxone 8.75mg/IV Q12, Metoclopomide 7mg/IV Q8 as needed for vomiting,
paracetamol 250mg/5ml symp 7ml every 4hrs for temp 37.8,paracetamol 350mg/IV every 4hrs as
needed for temp 38.5.

• Discharge planning
• Instruct the patient to follow the home medications prescribed by the attending physician.
Advised the patient to perform exercises such as jogging or walking exercises in order to promote
muscle tone and to regain patient’s strength and condition. Encourage her to increase fluid
intake, urinate when there is an urge to urinate in order to prevent infection, proper positioning
during sleep and urinating frequently to avoid Urinary Tract Infection.
• Instruct the patient for follow-up check-up on her condition one week after she was discharge
and to repeat urinalysis after 7 days of antibiotic. Eat nutritious foods like fruits and vegetables.
Avoid eating salty foods, junk foods and acidic softdrinks.