A Case Study:

Urinary Tract Infection

INTRODUCTION
A Urinary Tract Infection (also called a UTI for short) is an infection of the body's system involved in excreting urine. This can take place in the kidneys, the ureter the bladder or the urethra. Most often this occurs in the urethra and bladder. Studies are inconclusive on this point. Some doctors theorize that as the uterus grows its increased weight can block the drainage of urine from the bladder, causing an infection. Urinary tract infections (UTIs) are one of the most common bacterial infections during pregnancy. UTIs are associated with risks to both the fetus and the mother, including pyelonephritis, preterm birth, low birth weight, and increased perinatal mortality. The prevalence rates of bacteriuria in pregnant women and nonpregnant women are essentially the same. UTIs are more common in women when compared with men, primarily because of the anatomic differences of the shorter urethra and its proximity to the vagina and the rectum. However, when pregnant women have a urinary tract infection, they have a higher risk for and increased occurrence of upper tract UTIs when compared with lower tract UTIs. Several physiologic changes occur during pregnancy that cause otherwise healthy women to be more susceptible to serious sequelae from urinary tract infections. The infections can be symptomatic or asymptomatic. Asymptomatic bacteriuria, as the name implies, is a positive urine culture without specific symptoms. Asymptomatic bacteriuria increases the risk for an upper tract UTI, also known as pyelonephritis. Treatment of asymptomatic bacteriuria reduces the risk of a symptomatic infection. The frequency of asymptomatic bacteriuria occurs in 2-7% of pregnancies, similar to the nonpregnant population. However, up to 40% of these may progress to symptomatic upper tract UTI or pyelonephritis, significantly more than in nonpregnant women.4 Several factors are associated with an increased frequency in various patient populations. Indigent patients have a 5fold increased incidence of bacteriuria compared with that of nonindigent patients. The risk is doubled in women with sickle cell trait. Other risk factors for bacteriuria include diabetes mellitus, neurogenic bladder retention, and a history of previous urinary tract infections.

PATIENTS PROFILE

Name Age Sex Civil Status Nationality Address Occupation Birthday Birthplace Date of Admission Admitting Physician Attending Physician Admission Diagnosis

: : : : : : : : : : : : :

Mrs. UTI 28 years old Female Married Filipino Cabilang Baybay, Carmona, Cavite Housewife May 22, 1982 Carmona, Cavite 10:36 am, August31, 2010 Dr. Salayog, Benjamin Jorge Dr. Elefante-Delacruz, Vilma PU 34 3/7 weeks AOG by LMP G2P1 T/C UTI

PAST MEDICAL HISTORY

It was her second hospitalization in Binan Doctors Hospital after she delivered her 1st child via normal spontaneous vaginal delivery last November 7, 2007. She has no known cause of allergies, and doesnt have any habits of smoking and alcohol consumption. She actually no known family medical history of hypertension, diabetes mellitus and etc. She was now at her second pregnancy PU 34 3/7 weeks AOG by her last menstrual period of January 01, 2010 and possibly via normal delivery. She is currently not taking any medications but she was having monthly and weekly prenatal check-ups in their Barangay health center and also for immunization.

HISTORY OF PRESENT ILLNESS

Three days prior to patients admission, Mrs. UTI noted having hypogastric tenderness with pain and discomfort with no associated signs and symptoms until one day of prior to admission patient felt hypogastric pain and tenderness which is now associated with inability of walking which was her chief complaint. She was on her second pregnancy after a number of tests and examination by her admitting physician Dr. Dr. Salayog, Benjamin Jorge she as admittedly diagnosed with UTI, she was referred to her now attending physician/OB-gyne to supervise her now condition. She was transferred to the labor room for monitoring of fetal heart rate as well as to alleviate uterine contraction through tocolysis.

PHYSICAL ASSESSMENT
Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, the group made every effort to recognize and respect the patients feelings as well as to provide comfort measures following appropriate safety precautions and patients privacy. A. General Physical Assessment Mrs. UTI stands 54, with a pulse rate of 91 beats per minute, respiratory rate of 20 cycles per minute, a blood pressure of 110/60mmHg and a temperature of 36.7 C. She is conscious and coherent upon interaction. She is in a complete bed rest without bathroom privilages, in a trendelenburg position with pillows under buttocks and lower legs with stable condition but in tolerable pain. B. Assessment of the Head Head is round in shape (normocephalic). Hair is long in length, thick and coarse, straight and evenly distributed over scalp. There is no presence of abrasions, lice or any infiltrations. C. Assessment of the Eyes Her eyes are proportioned, brown in color, round shape. Pupils constricts when diverted to light (PERRLA) and dilates when he gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blinks. D. Assessment of the Ears Ears are clean, no ear wax was noted and approximately of the same size and shape. Patient can hear normally when spoken softly.

E. Assessment of the Nose With narrow nose bridge. No swelling of the mucous membrane and presence of nasal hairs were seen. F. Assessment of the Mouth She has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is

free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon observation. G. Assessment of the Neck Neck has strength that allows movement back and forth, left and right. Patient is able to freely move his neck. Darker in color compared to other area of the skin maybe related to her pregnancy. H. Assessment of the Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. There is an absence of adventitious sounds upon auscultation. Respiratory rate 18 breathes per minute from the normal range of 1620 breaths per minute. I. Assessment of the Heart There is a visible distribution of hair from the chest wall.Patient has an audible heart sound upon auscultation of the S1 and S2 caused by the closure of the valves. Heart is pumping well with a pulse rate of 91 bpm from the normal rate of 60-100 beats per minute. J. Assessment of the Abdomen Upon inspection on the skin of the abdomen is uniform in color and slightly lighter than exposed areas and globular in shape with a fundic height of 32 centimeters. There are striae gravidarum and linea nigra along the abdomen. There is a active bowel sound upon auscultation. Abdominal movement as with respiration. With presence of fetal heart tone in Right lower quadrant (FHT: 158 BPM) K. Assessment of the Upper Extremities Skin: White in color. Skin is smooth, moist and soft to touch with good skin turgor. Theres a presence of edema along the lower legs. Skin is warm to touch. Hands: Medium in size with 5 fingernails in each side. Nails are light pink in color, smooth and firm to touch short with brisk capillary refill of 1-3 seconds. Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side. L. Assessment to the Lower Extremities Size of the feet is undefined with lines on the sole, without presence of scars and lesions. Ten fingers are present. Patient was unable to move one of his legs due to presence of pain below the hypogastric area maybe possibly in her pelvic brim leading to inability to walk comfortably.

M. Assessment of the Genitourinary She urinates infrequently (difficulty on urination). She has a bright scanty amount of yellow urine. There is the urgency of urination but unable to pass through urine (urinary incontinence). O. Neurological Assessment Behavior Patient is having a facial grimace due to pain but is conscious and coherent upon interaction. Motor Functioning The patient is unable to move her legs comfortably due to presence of pain. But she was able to extend arms in front and resist active as pushed down/up on her hands. Reflexes Some of the reflexes were noted such as blinking, coughing or gag reflexes are present. Sensory Functioning Patients sensory system is intact, she was able to distinguish touch, pain, hot and cold.

ANATOMY ANDD PHYSIOLOGY

Kidneys The role of the kidneys is to cleanse the blood and balance its fluids:

They manufacture urine to filter out substances that the body does not need. They also take nutrients and other substances from the urine and return them to the blood.

Urine is manufactured in the kidney's renal tubules. There are approximately one million of these in each kidney. The raw material the body uses to manufacture urine is filtered blood serum, which is the plasma portion of the blood (minus proteins and blood cells).

The renal tubules process the filtered blood serum and remove the substances that will become urine These tubules lead into collecting ducts. These ducts empty the urine into small chambers referred to as renalcalyces he calyces funnel the urine into the renal pelvis, a basin-shaped cavity at the base of each kidney.

Ureters The ureters are tubular organs that lead from the renal pelvis of the kidney to the bladder. The ureters transport small quantities of urine when their muscular walls contract rhythmically. This pushes the urine in a wave-like fashion through the ureters from the kidneys to bladder. Bladder The bladder is a storage organ for urine. The bladder wall has the capacity to stretch like a balloon, enabling the bladder to expand as the volume of urine increases. When enough urine is in the bladder, receptors that respond to the stretch in the bladder wall will send electrical signals to the brain. This creates the need to urinate. Urethra The urethra is a tubular organ that transports urine from the bladder to the outside of the body.

In men, the urethra runs through the penis. In women, the urethra has its own opening within the vagina

Inside the body, the urethra is surrounded by a muscle that a person can control. This muscle must relax in order for urination to occur.

Predisposing factors: Poor hygiene Poor intake of water Inadequate nutritions Sexual Intercourse Physiologic changes in pregnancy

PATHOPHYSIOLOGY

Physiologic changes during pregnancy predispose such women to bacteriuria

Urinary retention caused by the weight of the enlarging uterus. The uterus sits directly on top of the bladder. As the uterus grows, its increased weight can block the drainage of urine from the bladder

Invasion of bacteria such as Escherichia coli (most common, in as many as 70% of cases) which was originated from fecal floras that colonize the periurethral area (ascending infection)

Leading to different signs and symptoms of infection: Feeling an urgent need to urinate or frequent urination. Having difficulty urinating. Having a burning sensation or cramps in the lower back or lower abdomen. Having a burning sensation during urination. Urine that looks cloudy or has an odor. Chills, fever, sweats

IF TREATED: Medical management Nursing management

IF NOT TREATED: It may lead to different complications such as: Kidney infections which may interfere with pregnancy, causing early labor and/or low birth weight (pyelonephritis) Causing a permanent scar or damaged to kidney which can be detrimental for both mother and child inside the womb.

Good prognosis

Recovery

Sepsis

DEATH

MEDICAL MANAGEMENT
Suggested for some routine diagnostics examinations such as urine analysis and culture and sensitivity tests which is safer tests for pregnancy to determine if pus, red blood cells or bacteria are present and to analyze the causative agent present and antibiotics which can be suggested to certain strains of MCO. Requested for some other examinations such as Complete blood count, platelet count, sodium-potassium, and pelvic ultrasound. Taking 3-7 day full course of antibiotics that is safe for the mother as well as to the baby. Ampicillin 1gm IV q6 (-) ANST

Increased oral fluid intake/hydration

Monitoring of vital signs q4 Fetal heart tone monitoring q1 Ordered on Diet as Tolerated

NURSING MANAGEMENT

LABORATORY
Laboratory #1: Urinalysis Result Color Reaction Transparency Specific Gravity Albumin Yellow pH 6.0 Sl. Hazy 1.020 Trace Normal Values Physical Straw- Dark yellow 4.6-6.5 Sl. Hazy 1.016-1.022 Chemical (-) negative Indication Normal Normal Normal Normal Albuminuria
Monitor for signs and symptoms of infection Monitor V/S Increase fluid intake Salt restriction

Nursing Management

Sugar Ketones RBC Pus Cells Squamous Bacteria

(-) (-) 2-4/ HPF 15-20/ HPF Many Many

(-) negative (-) negative Microscopic 0-2/HPF 0-2/HPF (-) negative (-) negative

Normal Normal Hematuria Bacterial infection infection Bacterial infection

Monitor intake and

output. Monitor for signs and symptoms of infection Monitor V/S Increase fluid intake Instruct don't resist the urge to urinate. Encourage Proper hygiene

Laboratory #2: Sodium Potassium Sodium Potassium Result 137.9 3.27 Normal Values 135-148 mmo/L 3.5-5.3 mmo/L Indication Normal Normal Nursing Management

Laboratory #3: Complete Blood Count Result 9.6 0.81 Normal Values 4.0-10 0.45-0.65 Indication Normal Increased, Infection Nursing Management
Monitor intake and output. Monitor for signs and

WBC Segmenters

symptoms of infection
Monitor V/S Increase fluid intake Instruct don't resist the urge

Lymphocytes

0.15

0.20-0.35

Decreased, Infection

to urinate. Encourage Proper hygiene Monitor intake and output. Monitor for signs and symptoms of infection Monitor V/S Increase fluid intake Instruct don't resist the urge to urinate.

Encourage Proper hygiene

Monocytes Eosinophils

0.04 0.00

0.02-0.06 0.02-0.04

Decreased, Infection

Monitor intake and output. Monitor for signs and

symptoms of infection
Monitor V/S Increase fluid intake Instruct don't resist the urge

to urinate.
Encourage Proper hygiene

Basophils RBC Hemoglobin

0.00 3.22 105

0.00-0.005 3.9-5.6 115165

Decreased

Monitor intake and output. Monitor for signs and

symptoms of infection
Monitor V/S Increase fluid intake Instruct don't resist the urge

to urinate.

Hematocrit

0.31

0.36-0.47

Decreased

Encourage Proper hygiene Monitor intake and output. Monitor for signs and

symptoms of infection
Monitor V/S Increase fluid intake Instruct don't resist the urge

to urinate.
Encourage proper hygiene

Platelet

221

150-350

Normal

Laboratory #4: Pelvic Ultrasound Impressions: Single line intrauterine pregnancy, 35 weeks by fetal biometry. Cephalic presentation, with good cardiac and somantic activities. Somantic activities Anterior placenta grade II Normohydramnios Sonographic estimated fetal Weight is appropriate for gestational age.

DISCHARGE PLANNING
Medications Instructed to follow prescribed medications and advised to avoid taking over the counter medicines without doctors prescription thus it will affect her child inside the womb. Exercise/Activities Participation in exercise, including kegel exercise and deep breathing exercise , can enhance circulation and aid in the elimination of blood congestion in the pelvic area. Treatments The first step in treating urinary tract infections is prevention. Prevention measures include drinking plenty of fluids, urinating as soon as possible when the urge is felt, and drinking cranberry juice, which may have infection-fighting qualities. For women, prevention measures include urinating promptly after having sexual intercourse, wiping the genital area from front to back after urinating or defecating, and not using douches or deodorant feminine products. These can be irritating to the genitals. Other treatments: o Treating Urinary Tract Infection by drinking water or fluids It is very important for your system to have a good flow of urine. This can be done by consuming plenty of water. It cleanses your body by diluting and flushing out the unwanted substance. o Treating Urinary Tract Infection by Cranberry Juice Cranberry juice disallows bacteria to cling to the cell, which line the urinary tract. It is a great remedy to fight this infection. If you cannot have the cranberry juice directly you can mix it with apple juice to add some taste. Health teachings For women with recurrent UTIs, give the following instructions: a. Reduce vaginal introital concentration of pathogens by hygienic measures.

b. Wash genitalia in shower or while standing in bath-tub bacteria in bath water may gain entrance into urethra. c. Cleanse around the perineum and urethral meatus after each bowel movement, with front-to-back cleansing to minimize fecal contamination of periurethral area. Drink liberal amounts of water to lower bacterial concentrations in the urine. Avoid bladder irritants coffee, tea, alcohol, cold drinks, and aspartame.

Out-patient/ Follow up Advise women with simple, uncomplicated cystitis that they do not require follow-up as long as symptoms are completely resolved with antibiotic therapy. But still follows the doctors order in case of there is a follow up check up to ensure that are no presence of infection especially if the case is pregnancy. Diet

Since bacteria that cause infections in your urinary tract cannot live in very acidic conditions, one of the suggestions you should heed if you are prone to urinary tract infections is to increase your intake of vitamin-C-rich foods and to drink citrus juices that have a lot of vitamin C. Not only will this increase the acidity of your urine, it will also make you more resistant to infection.

Some foods may have to be avoided when you have UTI, and these include processed foods, cheeses, and other dairy products. You may also need to avoid chocolates, coffee, and tea that have high caffeine content.

Other things you may need to avoid when you have urinary tract infections include spicy food, fizzy drinks or soda pop, beer, and other alcoholic beverages.

Try to increase your intake of healthy substances like vegetables and fruits. You can also have these in fresh juice form by juicing them or pureeing them. You can also mix fruit and vegetables in one healthy juice that you can drink every day for your health.