ACKNOWLEDGEMENT

Acknowledgement with the sense of appreciation and pleasure, I student of BNS 2nd year student
aspire to express my overwhelming and sincere thanks to the following persons that prolonged
their never ending support, advices, assistance and encouragement to the success of this case
study.

First of all , to our cherished campus chief, Ms. Pramila dewan, for raising academic excellence
in Bir Hospital Nursing campus . BNS 2nd year Co-ordinator, Ms Binda Ghimire, Respected
Madam Ms.Janaki Dhami, Ms.Sochana Sapkota, Ms. Maiya Manandhar and other associated
teachers for providing me opportunity to practice my clinical duty in Paropakar maternity and
womens health hospital , BN faculty members and all library staffs of Bir Hospital Nursing
Campus,BHNC for their kind cooperation and help in searching and providing necessities for
case study.

I would like to express my gratitude thanks to respected Madams for their continuous guidance,
support, encouragement and sedulous leadership throughout the case study.

My very special thanks to all staffs of Paropakar maternity and women health hospital for
permitting me to conduct case study and help during the entire case study.

I am also thankful to all my colleagues for their valuable commitment, suggestions, insight and
sharing of experience.

At last but not the least, I would like to express sincere thanks to my patient Ms. Asha Rai and
her husband Mr. Nawaraj Rai for his kind cooperation in providing information, allowing doing
procedures, assisting in providing nursing care to complete my case study successfully.

I still confess, as a student, I have learnt a lot from those work and take full responsibility for
error and omission.

Yours sincerely:

Ruja Shakya

BNS 2nd year

Roll no: 24

1
 TABLE OF CONTENT

ContentsPage no.
Background....3
Objectives ..4
Patient profile.5
History Taking....5-10
Postnatal Examination.11-16
Newborn examination..16
Developmental Tasks ...17
Anatomy and Physiology .18-21
Disease Description:
Definition, classification, epidemiology..22
Risk factor and Etiology 23
Related research article24
Pathophysiology25
Clinical manifestation(In book and in my patient)....26
Diagnosis.......27
Related research article..28
Diagnosis done in my patient.29
Investigations of my patient..........30
Management31-32
Drugs used in my patient..33-38
Application of Nursing Theory...39-40
Nursing Care Plan41-45
Daily Progress Notes46
Health teaching during hospitalization47
Discharge Teaching.47
What I learn from case study48
Research article..........49
Conclusion.50
References 51

2
 BACKGROUND

This case study report on Post Partum UTI is prepared on the basis of the study performed
during my six weeks maternity and gynaecological Practicum in Paropakar maternity and
womens health hospital . As well as this is done as a partial fulfillment of Bachelor of Nursing
Science Curriculum in Midwifery Nursing Practicum.

Postpartum UTI is the most common infection in peuperim period. Postpartum women suffered
from a Urinary Tract Infection (UTI) before and may recall that it definitely was not fun.

A UTI occurs when there is a significant number of bacteria present in your urinary tract. 20%
of women aged between 20 65 years suffer at least one attack per year and around 50% of
women will experience UTI at least once in their lives.

The whole case study focuses on patient holistic care. In this case study, I tried to find out any
lack in developmental task of my patient in comparing with book according to age. In this case
study I applied the knowledge of basic sciences, nursing theory and other related courses to plan
and implement nursing care. I explained them about the disease condition, its causes,
management and also provided them informations regarding common health problems,
characteristics of post partum period, adjustments to life. I also collaborated with patient and
health team members in every aspect related to patient health.

I have utilized the knowledge of teachers, colleagues as well as referred different books, websites
and record in preparing this case study. I have learned a lot from teachers and colleagues which
made me able to perform my task and prepare this case study.

As per bachelor of nursing curriculum, I was assigned various kinds of responsibilities during
midwifery posting. I had to conduct one case study during six week midwifery practicum. For
my case study, I selected a case of Postpartum UTI. In future, as a middle level health care
manager, this study will help us to identify the case and manage them on time and appropriately
working together with community which will contribute to the nation in reducing untimely
mortality and morbidity rate.

3
 OBJECTIVES OF MY CASE STUDY

General Objective:

General objectives of this case study is to provide holistic care to patient through nursing process
using appropriate nursing theories and also considering patients socio-cultural background and
traditional philosophy and practices with the help of knowledge from basic science and
fundamental nursing knowledge.

Specific Objectives:

To gain specific knowledge about specific disease.

To plan and implement comprehensive care of the client, using the knowledge gained
from basic science and nursing theory.
To learn to perform systemic and neurological examination methodically and correctly.
To identify the cause, pathophysiology, clinical features and diagnostic evaluation of Post
partum UTI.
To formulate nursing diagnosis and priorities nursing care plan according to patients
needs.
To provide individualized quality care to the patient by using a holistic nursing care and
problem solving approach.
To establish rapport and gain the trust and co-operation of the patient and her family.
To provide emotional and physical support to patient and her family during the treatment
process.
To facilitate communication by providing proper counseling to the patient and her family
regarding her condition.
To disseminate information to the health care team, care providers as well as her family
about the illness and how to care for the patient.
To evaluate daily progress of the patient health and effectiveness of treatment.
To work together with patient and other health worker to plan the daily care and
complications prevention.

4
 HISTORY TAKING

Patients profile/ biodemographic data:

Name : Mrs.Asha Rai

Age/sex : 19 years/female

Address : Permanent- Sindhuli

Current- Kathmandu

Date of admission : 2074/2/21

Patient no. : 1445566

Marital status : Married

Duration of marriage : 5years

Education : 5 class

Religion : Hindu

Ethnic group :

Occupation : business

Diagnosis : 6th postpartum day with UTI

Date of interview : 2074/2/22

Information obtained from:

Patient

Others :

- Husband

- History taking & physical examination.

- Laboratory investigation.

- Patients chart.

5
Health history of the patient:

A. Chief complains:

Burning micturation for 2days

Frequency and urgency of urine for 1day

Fever with chills for 1day

Lower abdominal pain for 1 day

B. History of present illness:

According to the patient she was apparently well 3 days back then on 4th post partum day
she developed burning micturation associated with frequency, urgency and lower
abdominal pain. She also complains of fever or 1 day associated with chills and rigor. No
nausea, vomiting, cough, SOB, etc. Then she was brought to Paropakar maternity and
womens health hospital, Emergency department. After she was admitted in Postnatal care
(PNC) ward with the diagnosis of 6th post partum day with UTI.

C. Past history:

Childhood illness: No history of Childhood illness .

Adulthood illness: Non significant illness as per the history except the present problems
like Hypertension, Hypothyroidism.

ADULT ILLNESS YES NO

High Blood Pressure No

Heart Disease No

Tuberculosis No

Diabetes Mellitus No

Filariasis No

Malaria No

6
 Cancer No

Asthma No

Hypothyroidism No

Others No

Psychiatric illness: No history of psychiatric illness.

Accidents & injury: No any major accidents and injury occurred in her life till now.

Immunization: Cannot be obtained.

Operations: She has no any history of surgical procedure.

Hospitalizations: No any history of previous hospitalizations.

Allergy: None; she has no any allergy to food, drugs, environment & any other things.

D. Menstrual history:

Age of menarche : 13years

Menstrual history : 28-32 days

Regularity : regular

Amount of blood loss: Normal

Duration of blood loss: 3-4 days

Last date of menstruation: 2073/05/14

E. Obstetric history:

Previous obstetric history:

Gravida : 2

Para : 1

7
 Live : 1

(She has a history of previous spontaneous abortion at 2months about 2 years ago.)

Present obstetric history:

LMP :2073/5/14
EDD :2074/2/21
Date of delivery :2074/2/16
Delivery type : Normal delivery with 2o tear
Delivery resul : Live male baby
Birth weight : 3330gm

F. Family history:

There is history of tuberculosis and epilepsy of her father and was treated for the disease
condition. Besides there is no history of other chronic illness like diabetes, hypertention,
thyroidism, kidney disease, etc

8
 FAMILY TREE

Paternal side Maternal side

(Unknown) (unknown) (unknown) (unknown)

52yrs 50yrs 46yrs 44yrs 42yrs 44yrs 42yrs 39yrs 35yrs

26yrs 24yrs 22yrs 19yrs 31yrs 18yrs 16yrs

6days(healthy)

Index

-Male
-Female

-demised

- Patient

9
 - Relation
- Siblings

Personal history:

Patient is non alcoholic and non smoker. Patient like normal nepali food. Patient has no
habit of day napping. Patient has normal bowel and bladder habit.

G. Socioeconomic history:
Patient lives in single family with her husband in a rented house. They run grossary shop
and able to afford optimum health expenses. There is well supply of drinking water and
sanitary toilet.

H. Cultural Health Belief and Practices:

They believe in both spiritual and modern health services. Patient is opstimistic towards
life.

10
 POSTNATAL PHYSICAL EXAMINATION

Physical examination reveals 15% of the information used in overall assessment. Physical
assessment also reveals problems that the patient has not recognized. Systematic approach
should be used while doing physical examination to avoid omission. We should always follow
the cephalo-caudal approach. I performed the physical examination of the patient systematically
using the step of physical examination like measurement, inspection, palpation, percussion &
auscultation which was very helpful in identifying problem & plan for care. I performed
physical examination of Mrs. Asha Rai on 2074/02/22.

Anthropometric measurements:
Height: 5ft
Weight: 55kg
BMI:

Clinical measurements:

Blood pressure: 12O/80 mmhg

Temperature: 101oF

Pulse: 80bpm

Respiration: 22 breaths/ min.

General appearance:

Patient is fully oriented to time, place and person. Posture is upright. Gait is smooth and equal
for the clients age and development. Clothing reflects gender, age and development

SYSTEMIC PHYSICAL EXAMINATION:

Integumentary system:
Inspection:
Fair complexion without cyanosis, rashes any patches or any lesion. No bleeding, laceration and
bruising. Firm, smooth, soft, elastic skin

Palpation:
Generalised warmth. Skin turgor was normal
Lymph nodes:

11
No any palpable lymph nodes (pre auricular, post auricular, submental, submaxillary, cervical,
axillary, inguinal lymph nodes) present over her body.

Head and face

Inspection:
Well distributed, black, oily hair present. No any dandruff, mass and lesions.

Palpation:
No swelling, lump or injury over scalp or forehead. No tenderness over the sinuses.

Eyes:

Both eyes were symmetrical in shape, size and location with equal movements.
No bulging of eyes.
No redness or discharge from the eyes.
Eye Brows: symmetrical, well distributed. No eye brows fall.
Eye Lids: no redness, edema, lesion and dropping were present.
Eye Lashes: outward and upward curled.
Conjunctiva: pinkish, no any infection and inflammation.
Pupil: round and uniform in shape and size. Constrict in bright light and dilate in dim light.
Lens: transparent
Eye Movements: normal
No any signs of anemia or jaundice. Extra ocular eye movement is normal. Peripheral vision is
normal.

Ears:
Inspection:

Normal shape, size and symmetry.

Top of pinna meets eyes at the line of outer canthus of the eyes.
No lump, lesion or discharge.
No redness, mass or foreign body present on the external auditory canal.

Palpation:
No any tenderness or swelling present on the mastoid bone.
Hearing activity: normal hearing capacity
12
Nose:

Medially located. Nostrils uniform in size& do not flare on respiration. Nasal septum is
not deviated.
No lesion, redness, tenderness or blockage of nasal pathways.
Intact smelling sense.
Mouth and throat:
Lips: looks dry and dehydrated. Cracks was present.
Gums: pink without bleeding or swelling.
Teeth: No missing teeth but dental caries in lower molar teeth present. Oral hygiene was not
maintained.
Tongue: No tongue tie present. Can identify the sense of taste. No signs of injury. But
dryness of tongue present.
Palate and uvula: dry and pink. No any signs of injury in palate and uvula located in midline
of the throat.
Throat: tonsils are not inflamed.
A. Neck:
Head positions centered in the midline and the head is held erect. Lymph nodes are not
visible. Trachea is in midline. Thyroid gland is not palpable.

B. Chest
Breast:
Size & shape- symmetrical in size & shape, nipples point to the same direction, good
milk secretion present, it is soft & non tender. Pale linear striae and stretch marks present.
Good attachment during breastfeeding.

Respiratory system
Inspection:
Trachea and sternum are located in a midline.
Normal in shape and symmetry.
Equal expansion of chest bilaterally during inspiration and expiration.

Palpation:

No tenderness, lumps or depression present along the ribs.

No any tenderness present in different sites of chest.
Percussion:

13
 Resonant sound heard over the lungs.
Dull sound over the heart.
Auscultation:

Clear breathe sounds present over all areas of lungs with no added breathe sounds
(wheezes, crepitation, rhonchus) .
Bronchial breathe sounds over trachea heard where inspiration was shorter than
expiration.
Bronchovesicular breathe sounds lateral to the trachea heard where inspiration
and expiration both are equal.
Vesicular sound was present over peripheral areas of the lungs over entire lungs
field where expiration was shorter than inspiration.
Cardiovacular system

Regular heart beat with rate of 74beats/min.

S1S2 (lub/ dup) present with no other added sounds or heart murmer.
Apex beat heart on fifth intercostals space mid clavicular line.
Peripheral pulses (brachial, radial, femoral, posterior tibial and dorsalis pedis)
were palpable.
Apex beat is symmetrical with other peripheral pulses i.e. 70 per minute
Pulse deficit is 4 per minute
Capillary refill time is less than 2 sec.
Palms of hands appear pink.
C. Abdomen
Inspection:
Cylindrical in shape.
Whitish striae and stretch marks are present.
Auscultation:

Gurgling peristalsis movement audible on all the four quadrants within 2 to 5

seconds.
No bruits sound heard over the aorta & renal arteries.
Palpation:

Uterus well contracted , fundal height 7cm.

No any pain, tenderness or other palpable mass was present over entire abdomen.
Femoral pulses: bilaterally equal.
Inguinal nodes: not palpable, non tender.
Liver: no tenderness or palpable per abdomen.
Spleen: no tenderness or palpable per abdomen.

Percussion:

Dull sound over right and left hypochondriac and umbilical region.
Tympanic sound present on other region.
14
 No tenderness, shifting dullness, gaseous distention or bladder dullness.
Stomach tympany in epigastrium & left hypochondrium.
Spleenic dullness below 9th interspace posterior to mid- axillary line & posterior
to anterior axillary line on deep inspiration.

D. Genitourinary system
No redness or swelling in labia, urethral opening appears stellate and in midline.
3 stiches seen externally in the perineum.
Mimimal lochia alba was present.

E. Back
Inspection:

No deformity on the back is seen.

No any swelling present over lumbar and back region.
Palpation:
Vocal fremitus present.
Bilateral equal expansion of back during respiration.
Percussion:

Resonance sound present over the back.

Auscultation:

Bilateral clear breathe sound heard over the back.

F. Upper and lower extremities

No bones and joints deformities

No redness and swelling of joints
No muscle wasting
Full range of joint movement
Symmetrical in shape and size
Equal strength in both hands and feets
No muscular weakness

G. Neuromuscular system
Level of consciousness: conscious but not well oriented to time, place and person
Flaccid, rigid and diminished strength & co-ordination on both right and left sides
of extremities.
Hold and grasp on something but cannot lift objects and resting tremor was
present
Sensory and motor functions are altered and diminished the motor function of all
extremities.

15
 Able to feel the touch.

Reflexes:
Right Bicep and triceps, brachioradialis, abdominal reflex, knee-jerk, Achilles,
Babinski and plantar reflexes are present. But absent left patellar and knee jerk
reflex.
Patient does not shows normal response to stimuli.

Cerebellar signs:
Finger nose finger: able to do.
Finger to thumb: able to do
Romberg: able to know position by closing eyes.
Posture/ gait: normal posture
Shallow knee bend: able to bend knee easily.

CONCLUSION:
On head to toe complete physical examination , Patient was ill looking, anxious and
complaining of burning micturation. Patient had fever 1010f . Patient had good milk secretion
and good attachment during breastfeeding. Uterus was well contracted, fundal height was 7cm,
per abdomen linea nigra and striae gravidarum present. In vaginal examination minimal lochia
alba present. Homens sign was negative.

BABY EXAMINATION:
On 2074/2/22, head to toe physical examination was done. On examination : VITAL SIGNS:
Height 50cm, weight 3330gm,
head circumference33cm.
HEENT: Head is normocephalic. Anterior fontanelle is open and flat. Red-orange reflexes are
positive in both eyes. Nose is clear. Mouth is clear.
NECK: There is no neck mass.
CHEST AND LUNGS: Symmetric. Good air entry and clear breath sounds.
HEART: Quiet precordium. Regular rhythm. No murmurs heard. Normal first and second
heart sounds.
ABDOMEN: Flat, not distended, soft, no mass, no tenderness. The umbilical cord is dry, but
still attached.
EXTERNAL GENITALIA: Normal male. Both testes are descended. He has perianal rash and
a small amount of stool in his perianal area.
SKIN: Generally clear. He has some salmon patches on his buttocks.
NEUROLOGIC: Examination is grossly intact and normal.
Good attachment during breastfeeding.

16
 DEVELOPMENTAL TASK:
According to WHO adolescent is the period of life from 10-19 years. Since my patient is 19years
old, she is categorized under adolescent (later childhood) group. Adolescent is a period of
transition from childhood to adulthood. It is time of rapid physical, cognitive, social and
emotional maturing to develop womanhood or manhood.
Adolescent experience significant physical growth and development during puberty , which
in turn considerably increases their requirements for calories, protein and vitamins and minerals.
Adolescent also experience significant changes in their ability and in their desire to become
independent, unique individuals.

During this period the individual has to fulfill the following task.

Developing more mature relations with the same sex age mates and learning new
relationship with member of the opposite sex.
Accepting the changing body size, shape and function and understanding the meaning of
physical maturity.
Achieving sexually acceptable feminine or masculine role.
Achieving emotional independence from parents and other adults.
Preparing economic career to be economically independent.
Acquiring the set of value and ethical system to guide to his/her ideology and behavior.
Achieving socially responsible behavior.
Developing the intellectual and work skills.
Preparing for marriage and family life.

My patient was able to achieve all the developmental task.

17
 ANATOMY AND PHYSIOLOGY

The urinary system is one of the most important and chief excretory system of the body.

The urinary system refers to the structures that produce and conduct urine to the point of
excretion. The human body normally has two paired kidneys, one on the left and one on the
right. Urine is formed by nephrons, the functional unit of the kidney, and then flows through a
system of converging tubules called collecting ducts. The collecting ducts join together to form
minor calyces, then major calyces, which ultimately join the pelvis of the kidney (renal pelvis).
Urine flows from the renal pelvis into the ureter, a tube-like structure that carries the urine from
the kidneys into the bladder.

During urination, urine stored in the bladder is discharged through the urethra. In males, the
urethra begins at the internal urethral orifice in the trigone of the bladder, continues through the
external urethral orifice, and then becomes the prostatic, membranous, bulbar, and penile urethra.
Urine exits through the external urethral meatus. The female urethra is much shorter, beginning
at the bladder neck and terminating in the vaginal vestibule.

18
FUNCTION
There are several functions of the Urinary System:

Formation and secretion of urine.

Excretion of urine from body(eg. Micturation) thereby eliminating various waste products,
substance (eg. Drugs)which would be toxic if allowed to accumulate in the body.
Removal of waste product from the body (mainly urea and uric acid)
Regulation of electrolyte balance (e.g. sodium, potassium and calcium)
Regulation of acid-base homeostasis
Controlling blood volume and maintaining blood pressure

Its indeed is referred as the ultimate regulator of homeostasis.

a) The kidney-2 which secretes urine
b) The ureter-2 which drain the urine from the kidney to urinary bladder.
c) The urinary bladder-1 , act as urinary reservoir where urine is collected and stored
for short period of time(temporarily).
d) The urethra-1, a canal through which the urine is eliminated from the urinary
bladder.

KIDNEY:
The kidneys are two bean-shaped organs found on the left and right sides of the body
in vertebrates. They filter the blood in order to make urine, to release and retain water, and to
remove waste and nitrogen (the excretory system). They also control the ion concentrations and
acid-base balance of the blood. Each kidney feeds urine into the bladder by means of a tube
known as the ureter. In humans, they are roughly 11 centimeters (4.3 in) in length. In adult
males, the kidney weighs between 125 and 170 grams. In females the weight of the kidney is
between 115 and 155 grams.

The kidneys are located high in the abdominal cavity, one on each side of the spine, and lie in
a retroperitoneal position at a slightly oblique angle. The asymmetry within the abdominal
cavity, caused by the position of the liver, typically results in the right kidney being slightly
lower and smaller

The kidneys are dark red in color which is embedded in a pad in a pad of fat called the peritoneal
fat, which keeps the kidney in position. The right kidney is slightly lower than left.

FUNCTION OF KIDNEYS:
The primary function of the kidney is to secretion urine which passes through the ureter
to the bladder for excretion.
The excretion of water that is excess in the body , thus maintains water balance.
The excretion of the electrolytes and the ions, thus maintains electrolyte balance.
The excretion of the end products of protein metabolism.
The excretion of drugs, toxins and other chemical substances which may be harmful to
body.
19
 Secretion of erythropoeitic hormone, which is necessary for RBC production.
Formation of 1,25-dihydroxychole-calciferol. Cbiologicaly active vitamin D)
Regulation and maintenance of blood pressure.

URETER:
the ureters are tubes made of smooth muscle fibers that propel urine from the kidneys to
the urinary bladder. In the adult, the ureters are usually 2530 cm (1012 in) long and ~34 mm
in diameter.
There is no actual valve in the lower end of the ureter but the obliquity of its path through the
muscle of the bladder wall normally prevents the reflux of urine from the bladder into the
ureter(vesico-ureteric reflux). This mechanism may be disturbed in case of infection of the
urinary tract.

FUNCTION:
The ureters propel the urine from the kidneys into the bladder by peristaltic contraction of the
muscular wall.

URINARY BLADDER:
The bladder is a hollow muscular organ situated at the base of the pelvis. Urine collects in the
bladder, fed from the two ureters that are connected to the kidneys. Urine leaves the bladder via
the urethra, a single muscular tube which ends in an opening the urinary meatus, where it exits
the body.
Anatomically, the bladder is divided into a broad fundus, a body, an apex, and a neck.
The apex is directed forward toward the upper part of the pubic symphysis, and from there
the median umbilical ligamentis continued upward on the back of the anterior abdominal wall to
the umbilicus. The peritoneum is carried by it from the apex on to the abdominal wall to form
the middle umbilical fold. The neck of the bladder is the area at the base of the trigone that
surrounds the internal urethral orifice that leads to the urethra. In the male the neck of the
urinary bladder is adjacent to the prostate gland.
The three openings, two ureteric orifices, and the internal urethral orifice mark the triangular area
called the trigone of the bladder. These openings have mucosal flaps in front of them that act as
valves in preventing the backflow of urine into the ureters, known as vesicoureteral reflux.
The bladder can hold over 500ml of urine. Desire of micturation begins when the volume of
urine reaches to 250-300 ml.

Organs associated
In female:
Anterioly: The symphysis pubis
Posteriorly: The ureters
Superiorly: The small intestine
Inferiorly: The urethra and the muscle forming the pelvic floor.

20
STRUCTURE:
Composed of 4 layer:
a) Peritoneum: covers only the superior surface of bladder.
b) Muscle layer: this layer is composed of longitudinal and circular musle fiber.
c) Sub mucous layer
d) Mucous

Functions of Urinary bladder:

1. Serves as the reservoir of the urine before it leaves the body.
2. Expels urine from the body with the of urethra.

URETHRA:
The urethra is a tube that connects the urinary bladder to the urinary meatus for the removal of
fluids from the body. In males the urethra travels through the penis, and carries semen as well
as urine In females, the urethra is shorter and emerges at the urinary meatus above the vaginal
opening.
Females use their urethra only for urinating, but males use their urethra for both urination
and ejaculation. The external urethral sphincter is a striated muscle that allows voluntary control
over urination. Only in the male is there an additional internal urethral sphincter muscle
In female, the urethra is about 1.9 inches (4.8 cm) to 2 inches (5.1 cm) long and exits the body
between the clitoris and the vagina, extending from the internal to the external urethral orifice.
In male, the urethra is about 8 inches (20 cm) long and opens at the end of the external urethral
meatus.

FUNCTION:
1. Act as passage way for eliminating urine from the body.
2. In addition, in the male, the urethra is also the terminal portion of the reproductive tract and
serve as the passage way for the reproductive fluid semen.

21
 DISEASE PORTION
INTRODUCTION

Urinary Tract Infection:

Presence of an infective agent anywhere between the kidney and the urethral meatus can
develop infection. These infection are called urinary tract infection (UTI) (The normal urinary
tract is sterile tract above urethra.
Urinary tract infection can occur following childbirth resulting from hypotonia of bladder,
lower urinary tract infection ,birth trauma, catheterization, frequent vaginal examinations and
anesthesia.
During birth, the bladder and urethra can be traumatized by pressure from the descending
fetus. Following birth, a hypotonic bladder and urethra can increase the urinary stasis and urinary
retention. Urinary infection are usually caused by coliform bacteria such as E-coli.

CLASSIFICATION OF UTI:
It is classified by location.
Upper UTI: involves the ureters, renal pelvis, calyces and renal parenchyma i.e. acute and
chronic pyelonephritis, renal abscess, interstitial nephritis, peri renal abscess.
Lower UTI: involves the urethra, bladder i.e. cystitis, urethritis

It can also be classified as:

a. Uncomplicated lower or upper UTIs
-community acquired infection, common in young women and not usually
recurrent.

b.Compliccated lower or Upper UTIs

-often nosocomial (acquired in the hospital) and related to catheterization, occur in
patients with urologic abnormalities, pregnancy, immuno suppression diabetes mellitus, and
obstructions and are often recurrent.

EPIDEMIOLOGY:

A UTI is the second most common infection in the body. Most cases occur in women.
1 out of every 5 women in United states will develop UTI during her life time.
The urinary tract is most common site of nosocomial infection, accounting for greater
than 40% of the total number reported by hospitals and affecting about 600,000 patient
each year.
The incidence of post partum UTI is about 2.8% overall including caesarean sections and
normal vaginal deliveries. It is higher after c/s possibly due to catheterization and use of
sanitary pads pads post partum may also contribute the higher incidence of UTI.

22
RISK FACTOR:
Inability or failure to empty the bladder completely.
Obstructed urinary flow caused by:
o Congenital abnormalities
o Urethral stricture
o Contracture of the bladder neck
o Calculi(stones) in the ureter or kidney
o Compression of ureters
Decreased natural host defenses or immune suppression
Instrumentation of urinary tract (eg. Catheterization, cystoscopic procedures)
Inflammation or abrasion of urethral mucosa
Contributing factors/condition such as:
o Diabetes mellitus (increase urinary glucose levels create an infection prone
environment in the UTI)
o Pregnancy, h/o caesarean section, PROM, frequent cervical examination
o Neurological disorder , internal fetal monitoring,
o Gout, nutritional status, diabetes, obesity.

ETIOLOGY

The commonest etiologic organism is E-coli(80%)

The remaining 20% are caused by gram negative bacteria such as proteus, pseudomonas,
Klebsiella, staphylococcus aureus, hemophilum and coagulase negative staphylococcus.

23
 RELATED RESEARCH ARTICLE:

TOPIC: Risk factor for urinary tract infection in postpartum period.

OBJECTIVES: We sought to examine risk factors for urinary tract infection in postpartum
women.

STUDY DESIGN:

stratified analysis was performed by using Mantel-Haenszel procedures.Subjects

(n = 931) with maternal urinary tract infections and control subjects (n = 1862) were
identified by using a linked Washington State birth certificate and Birth Events Records
Database
for the years 1987-1993

RESULT: Increased risk for postpartum urinary tract infection was associated with
black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence
interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval,
1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and
tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to
maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal
disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-
eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among
women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence
interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval,
1.84-13.64) were risk factors. Length of hospital stay was significantly associated with
urinary tract infection.

CONCLUSION: Maternal medical conditions and procedures that predispose to urinary

tract infections are those that also are associated with urethral catheterization. In
addition, maternal urinary tract infections may contribute significantly to duration of
postpartum hospital stay.

24
 PATHOPHYSIOLOGY

HOST ENVIRONMENT PATHOGENS

-Anatomy - Behavioral -Frequent sexual intercourse - E-coli adhesion
-High grade VUR -Voiding dysfunction - Spermicidal - Bacterial
reservoir

Periurethral colonization

Urethral organism enters bladder during micturation (due to short

female urethra and proximity to perianal areas)

Once in bladder, multiply then pass up the ureter (esp if VUR) to renal
pelvis and parenchyma

Damaged and inflamed mucous

Dextrusor irritation inflammatory cell, RBC, fibrin, other

glutinous product

Dextrusor spasm and leakage Urine analysis(leucocytes, erythrocytes,

Urothelial cells

UTI
25
CLINICAL FEATURES:
Urinary tract infections don't always cause signs and symptoms, about half of all patient with
bacteriuria have no symptoms but when they do they may include:

A strong, persistent urge to urinate

A burning sensation when urinating
Incontinence
Nocturia
Urine that appears cloudy
Hematuria
Strong-smelling urine
Back pain
Pelvic pain, in women especially in the center of the pelvis and around the area of the
pubic bone
UTIs may be overlooked or mistaken for other conditions in older adults.

Complicated UTI:
May range from asymptomatic bacteriuria to gram negative sepsis with shock.

. Lower UTI
Pyuria
Hypogastric pain/ abdominal
Frequency/ urgency of micturation
Foul smelling of urine
Incontinence
Burning micturation
Pressure or pain in the lower pelvis or lower back

Upper UTI
Fever, chills, rigor
Vertebral angle tenderness
Flank pain
Nausea and vomiting
Hematuria
26
 Leukocytosis

IN BOOK PICTURE IN PATIENT

A strong, persistent urge to urinate Present
A burning sensation when urinating Present

Incontinence Absent

Nocturia Absent

Hematuria Absent

Urine that appears cloudy Present

Strong-smelling urine Absent

Back pain Absent

Pelvic pain, in women especially in Absent
the center of the pelvis and around the
area of the pubic bone
Fever Present
Leucocytosis Present

27
 RESEARCH ARTICLE:
CAUSATIVE AGENTS AND SUSCEPTIBILITY OF ANTIMICROBIALS AMONG
SUSPECTED FEMALES WITH URINARY TRACT INFECTION IN TERTIARY
CARE HOSPITALS OF WESTERN NEPAL

Introduction:
Urinary Tract Infection (UTI) is a common and serious health problem affecting many people
each year around the World especially females. Therapy of UTI relies on the predictability of the
agents causing UTI and knowledge of their antimicrobial susceptibility patterns.
Study design:
A retrospective cross-sectional study was conducted in two major hospitals of Western Nepal.
Tools for data collection were a data collection form.
Result:
Total 400 patients file with suspected UTI were reviewed, out of which 173 (43.3 %) of the
suspected samples showed presence of potential pathogens causing UTI. UTI was mostly
prevalent in females of age group 21-30. Escherichia coli (E. coli) was the predominant (65.1%)
bacterial pathogen. Amikacin was found to be most sensitive antimicrobial followed by
Nitrofurantoin and Gentamcin. Ampicillin showed the higher percentage of resistant, compared
to other antimicrobials. As drug resistance among bacterial pathogens is an evolving process,
regular surveillance and monitoring is necessary to provide effective treatment of UTIs.

Journal of Chitwan Medical College 2013; 3(4): 16-19 Available online at: www.jcmc.cmc.edu.np

P Thapa # , K Parajuli # , A Poudel , A Thapa , B Manandhar , D Laudari , HB Malla , R Katiwada

School of Health and Allied Sciences, Pokhara University, Lekhnath, Kaski , Nepal. # Equal Contribution
as First Autho

28
Diagnostic investigations:
History taking
Physical examination
Urinalysis
Urine culture
To identify associated factors
Renal USG
IVP and renal scan
Imaging test: USG, x ray
Voiding cystourethrogram
Blood test:TC,DC, ESR, Hb, blood culture

DIAGNOSTIC TEST DONE IN MY PATIENT:

Complete history taking

Physical examination
Urine analysis:
o Routine
o Culture
Blood test

29
 FINDINGS OF LABORATORY INVESTIGATIONS DONE IN MY PATIENT

Date Investigation Result Normal

Value
2074/2/21 Haematological Test:-
=>Haemoglobin =>12.3/dl M=13.5-18gm/dl
F= 11.5-16.5gm/dl
=> Total WBC count =>11200/cmm 4,000-10,000/cmm
=> Total RBC count =>4.57/cmm 4.5-5.5/cmm
=>Differential Count:-
Neutrophil 77% 45-35%
Lymphocyte 23% 20-40%
Eosinophil 01% 0-4%
Monocyte 0% 2-8%
Basophils 0% 0-1%
=> Platelets => 2,49,000/cmm 150,000- 4,00,000/cmm

Biochemical Test:-
=> Blood glucose => 110mg/dl => 80-140mg/dl
=> Serum urea => 22mg/dl => 20-45mg/dl
=> Serum creatinine => 0.5mg/dl =>0.4-2.0mg/dl
=> Sodium => 143mEq/L =>135-145mEq/L
=> Potassium => 3.9mEq/L =>3-5mEq/L

Urine RE/ME:-
=>Colour => Yellow =>Light yellow
=>Transparency => slight turbid =>Clear
=>Albumin => 3+ =>Nil
=>Pus cells => packedPHF =>Nil
=>RBC => 8-10/HPF
=>Epithelial cells => 1-2/HPF

Urinec/s: =>multiple organism

growth

30
MANAGEMENT:
Management of UTIs typically involve Pharmacologic therapy and Patient education.
PHARMACOLOGIC MANAGEMENT:
The ideal medication for the treatment of UTI is an antibacterial agents that eradicates bacteria
from the urinary tract with minimal effects on fecal and vaginal flora.
Various treatment regimen have been successful in treating uncomplicated lower UTIs in
women.
1 . Inhibit bacterial growth

Antibiotics
Initially broad spectrum, then antibiotic according to culture report.
Penicillin, sulfonamide, cephalosporin, nitrofurantoin, aminoglycosides, fluroquinotone,
ciprofloxacin, norfloxacim, 3rd generation cephalosporin eg. Ceftriaxone and cefotaxim.

Some of medications commonly uses to treat UTI are:

DRUG CLASS GENERIC/BRAND NAME

Antibiotic Cephalexin Genito urinary infections
Cephalosporin (1st generation)
Antibiotic -Ampicillin Not commonly used alone due
-Amoxicillin to E-coli resistance
pyelonephritis
Trimethoprim Cotrimoxazole UTI, Pyelonephritis
sulphamethorazole
combination
Urinary tract anti-infective Nitrofurantoin UTI
Fluoroquinolone antibiotic Ciprofloxacin UTI, Uncomplicated UTI
Levofloxacin
Urinary analgesic agent Phenozopyridine(pyridium) For relief of burning pain and
other symptoms associated
with UTI.

Although brief pharmacologic treatment of UTIS for 3 days is usually adequate in women,
infection recurs in about 20% of women.
Reinfection with new bacteria is the reason for more than 90% of recurrent UTIs in women.

If the diagnostic evaluation reveals no structural abnormalities in the urinary tract, the
women with recurrent UTI may be instructed to begin treatment on her own whenever
symptoms occurs and to contact her health care provider only when symptoms persist,
fever occurs, or the number of treatment episodes exceeds four in a 6 month period.

31
 The patient may be taught to use dipslide culture devices to detect bacteria.

If the infection recur after completing anti microbial therapy, another short course (3-4
days) of full dose antimicrobial therapy, another short course (3 to 4 days) of full dose
antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may
be prescribed.
If the patient is suspected of pyelonephritis and has fever s/de should be admitted to the
hospital for IV antibiotics and symptomatic management.
Blood and urine culture at admission and following therapy and repeated at monthly
interval for 3 months and 3 monthly for another 6 month.
Surgical correction of anatomic defect if any.
Prophylactic antibiotic and careful follow up to prevent recurrent infection.
Increase fluid intake.
Management of pain and fever.

NURSING MANAGEMENT:

Help the patient to recognize UTI eg.frequent, voiding, constant squirming, abnormal
streams, straining, discomfort in starting and stopping, refuse ti urinate,
Relieving pain:
o The pain associated with UTI is quickly relieved once effective antimicrobial
therapy is initiated. Antispasmodic agent may be useful in relieving bladder
irritability and pain.
o Analgesic agent and heat application to perineum helps to relieve pain eg.sitz
bath.
Assist in diagnostic procedure
o Assist in collecting specimen as needed.
o Teach them about clean catch technique.
Eradication of infectious organism by administering antibiotic as prescribed.
Encourage patient to drink liberal amount of fluids (water is the best choices) to promote
renal blood flow and to flush the bacteria from urinary tract.
Encourage the patient to avoid urinary tract irritants (eg. Coffee, tea, citrus, spices, colas,
alcohol).
Emphasize importance of continued antibiotic therapy, regular urine examination
following an infection.
Encourage the patient to void frequently (every 2-3 hrs) to empty the bladder completely
because this can significantly lower urine bacterial counts, reduce urine stasis and
prevents reinfection.
Manage fever.
Promoting home and community-based care:
o Practicing careful personal hygiene.
o Increasing fluid intake to promote voiding and dilution of urine.
o Voiding habit: urinating regularly and more frequently.
o Adhering to complete therapeutic regimen.
32
 DRUGS USED IN MY PATIENT

SN DRUG FORM DOSE ROUTE TIME

1. Amoxicillin Tablet 500mg PO TDS

2. Urilizer Syrup 10ml Oral TDS

3. Aciloc Tablet 150mg Oral BD

AMOXICILLIN
Classification:

Therapeutic: anti-infectives, antiulcer agents

Pharmacologic: aminopenicillins

Pregnancy Category B

Indications:

Treatment of: Skin and skin structure infections, Otitis media, Sinusitis, Respiratory infections,
Genitourinary infections, Endocarditis prophylaxis, Post exposure inhalational anthrax prophylaxis,
Management of ulcer disease due to Helicobacter pylori.

Mechanism of action:

Action Binds to bacterial cell wall, causing cell death. Therapeutic Effects: Bactericidal action; spectrum
is broader than penicillin.

Route/Dosage:

Most Infections

PO (Adults): 250 500 mg q 8 hr or 500 875 mg q 12 hr (not to exceed 2 3 g/

day).

Contraindications/Precautions Contraindicated in:

Hypersensitivity to penicillins (cross-sensitivity exists to cephalosporins and other beta-lactams) ,

Use Cautiously in:Severe renal insufficiency; Infectious mononucleosis, acute lymphocytic leukemia, or
cytomegalovirus infection (q risk of rash);OB, Lactation: Has been used safely.

33
Adverse Reactions/Side Effects

CNS: SEIZURES (high doses).

GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, qliver enzymes.

Derm: rash, urticaria.

Hemat: blood dyscrasias.

Misc: allergic reactions including ANAPHYLAXIS,SERUM SICKNESS, superinfection.

Side Effects/Adverse effects:

lethargy, hallucinations, seizures, glositis, stomatitis, gastritis, sore mouth, furry tongue, black
hairy tongue, nausea and vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis,
pdesudomemebranous colitis specific hepatis.

Nursing Responsibilities

Culture infected area prior to treatment; re-culture area if response is not as expected.
Give in oral preparations only; amoxicillin is not affected by food
Continue therapy for at least 2 days after signs of infection have disappeared;
continuation for 10 full days is recommended.
Use corticosteroids or antihistamines for skin reaction.
Report any side effects
If GI upset occurs, take with meals

34
 ACILOC
Generic Name : ranitidine hydrochloride

Classification:
Histamine2 (H2) antagonist
Pregnancy Category B

Dosage & Route:

Available forms : Tablets75, 150, 300 mg; effervescent tablets and granules25, 150
mg; syrup15 mg/mL; injection1, 25 mg/mL
Adults: Active duodenal ulcer: 150 mg bid PO for 48 wk. Alternatively, 300 mg PO
once daily at bedtime or 50 mg IM or IV q 68 hr or by intermittent IV infusion, diluted
to 100 mL and infused over 1520 min. Do not exceed 400 mg/day.
Maintenance therapy, duodenal ulcer: 150 mg PO at bedtime.
Active gastric ulcer: 150 mg bid PO or 50 mg IM or IV q 68 hr.

Therapeutic actions:
Ranitidine blocks histamine H2-receptors in the stomach and prevents histamine-mediated
gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion
or serum gastrin.

Indications:
Short-term treatment of active duodenal ulcer
Maintenance therapy for duodenal ulcer at reduced dosage
Short-term treatment of active, benign gastric ulcer
Short-term treatment of GERD
Pathologic hypersecretory conditions (eg, Zollinger-Ellison syndrome)
Treatment of erosive esophagitis
Treatment of heartburn, acid indigestion, sour stomach

Adverse effects:
Headache, dizziness. Rarely hepatitis, thrombocytopaenia, leucopaenia, hypersensitivity,
confusion, gynecomastia, impotence, somnolence, vertigo, hallucinations.
35
Potentially Fatal: Anaphylaxis, hypersensitivity reactions.
Contraindications: Porphyria.

Nursing considerations:
Assessment:
History: Allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy
Physical: Skin lesions; orientation, affect; pulse, baseline ECG; liver evaluation, abdominal
examination, normal output; CBC, LFTs, renal function tests
Interventions:
Administer oral drug with meals and at bedtime.
Decrease doses in renal and liver failure.
Provide concurrent antacid therapy to relieve pain.
Administer IM dose undiluted, deep into large muscle group.
Arrange for regular follow-up, including blood tests, to evaluate effects.
Teaching points:
-Take drug with meals and at bedtime.
-Therapy may continue for 46 weeks or longer.
-If you also are using an antacid, take it exactly as prescribed, being careful of the times of -
administration.
-Have regular medical follow-up care to evaluate your response.
-You may experience these side effects: Constipation or diarrhea (request aid from your health
care provider); nausea, vomiting (take drug with meals); enlargement of breasts, impotence or
decreased libido (reversible); headache (adjust lights and temperature and avoid noise).
-Report sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations,
dizziness, severe headache, muscle or joint pain.

36
 Uriliser
Uriliser Syrup is used for Treatment of urinary bladder calculi, Renal tubular acidosis, Kidney
problems, Metabolic acidosis, Anticoagulation and other conditions. Uriliser Syrup may also be
used for purposes not listed in this medication guide.
Uriliser Syrup contains Citric Acid, and Potassium Citrate as active ingredients.
Uriliser Syrup works by possessing the calcium chelating ability; lowering the coagulation factor
activity; exhibiting the antioxidant action; providing potassium in the blood;

Uses:
Uriliser Syrup is used for the treatment, control, prevention, & improvement of the following
diseases, conditions and symptoms:
-Treatment of urinary bladder calculi
-Renal tubular acidosis
-Kidney problems
-Metabolic acidosis
-Anticoagulation

Mechanism of Action and Pharmacology:

Uriliser Syrup improves the patient's condition by performing the following functions:
Possessing the calcium chelating ability; lowering the coagulation factor activity; exhibiting the
antioxidant action.
Providing potassium in the blood.

Side-effects:
The following is a list of possible side-effects that may occur from all constituting ingredients of
Uriliser Syrup. This is not a comprehensive list. These side-effects are possible, but do not
always occur. Some of the side-effects may be rare but serious.

Abdominal pain
Cough
Shortness of breath
Sore throat
Redness
Confusion

Contraindications:

37
Hypersensitivity to Uriliser Syrup is a contraindication. In addition, Uriliser Syrup should not be
used if you have the following conditions:
- Acute dehydration
- Heat cramps
- Hyperkalemia
- Hypersensitivity
- Impaired renal function
- Severe myocardial damage

38
 NURSING THEORY APPLIED IN MY CASE

Application of Hendersons nursing theory related to independence to nursing process.

During my case study, I applied Hendersons theory while giving nursing care. Since Hendersons theory
focused more on the individual and his/her ability to perform. Hendersons view the patient as an
individual who requires assistance to achieve health and independence or peaceful death.

She gives definition of nursing in functional term; one unique function of the nurse is to assist the
individual, sick or well, in performance of those activities contributing to health or its recovery that he
would perform unaided, if he had the necessary strength, will or knowledge. And to do this in such a way
as to help him gain independences as rapidly as possible.

Henderson further identified 14 basic needs of the patient which comprise the component of nursing care.

Mrs. Aasha Rai, who had been admitted in PNC ward had the same need of care that is interrelated to the
Hendersons 14 basic components of nursing care.

Applications of Hendersons 14 basic components of nursing care in my

Patient.

Hendersons 14 basic components Application in my patient

1. Breathing normally 1. She had normal breathing pattern.

2. Eat and drink adequately 2. She is given normal balanced diet with adequate
fluids roughage and iron containing diet.

3. Eliminate body waste 3. She had burning micturation, frequency and

urgency for urination, however normal bowel
movement.
4. Move and maintain desirable postures 4. Positioned in such a way that is comfortable for
her.
5. Sleep and rest 5. Sleep is very important. We did not disturb her
while sleeping.
6. Select suitable clothes dress and undress. 6. She had proper clothing.

39
7. Maintain body temperature within normal 7. She had fever 101of so Body temperature was
range by adjusting clothing and modifying the maintained by adjusting clothing and modifying
environment the environment and providing cold sponging.

8. Keep the body clean and well groomed and 8. Patient was assisted in maintaining personal
protect the integument hygiene.
9. Avoid danger in the environment and avoid 9. Safe environment was maintained
injuring others.

10. Communication with others in expressing 10. She expressed these needs by verbalizing what
emotions, needs, fears and opinions. she wants and needs.

11. Worship according to once faith. 11. She prays god according to their faith.

12. Work in such a way that there is a sense of
accomplishment
13. Play or participate in various forms of
recreation
14. Learn, discover or satisfy the curiosity that
leads the normal development and health and
use the available health facilities.
12. She was assisted in accomplishing her task.
13. She was involved in recreation as per her
interest.
14. queries and health facilities of the hospital
available were adequately explained.

THE PROBLEMS PRIORITIZED ACCORDING TO HENDERSONS THEORY:

Nursing Diagnosis:
1. Acute pain related to inflammation and infection of the urethra, bladder, and other
structure as evidenced by burning on urination, facial grimace and lower abdominal pain.
2. Hyperthermia related to inflammation as evidence by increase body temperature (101of) ,
warm to touch.
3. Impaired urinary elimination related to frequent urination and urgency as evidenced by
urge and dysuria.
4. Deficient knowledge related to unfamiliarity with nature and treatment of UTI as
evidenced by lack of awareness,
5. Risk for fluid and electrolyte imbalance related to incomplete voiding.
6. Risk for recurrent infection related to decrease fluid intake and poor personal hygiene.

40
ASSESS- NURSING GOAL PLAN OF IMPLEMEN - RATIONALE EVALUA
MENT DIAGNOSIs ACTION TATION TION
Subjective Acute pain Client will -Assess clients -On assessment -Pain associated The goal
data: related to report description of patient has lower with UTI is was
Patient inflammation satisfa- pain such as abdominal pain described as achieved
said that and infection ctory pain quality, nature and intensified burning on as patient
I have of the urethra, control and severity of during voiding. urination,flank shows
pain in bladder and within pain. pain, lower smiley
lower other structure 1hour. abdominal or face and
abdomen as evidenced suprapubic pain verbalized
and by burning on comfort.
burning urination,facia - Suggest use of -Patient was -Alternative
non-pharma therapies may
micturatio l grimace, and provided guided
cological decrease pain
n. lower imagery ,
techniques as and provide
abdominal massage.
appropriate. comfort.
Objective pain.
data: -Encourage
-Facial increased oral -patient was -Increased
grimace fluid intake (2- encouraged to hydration helps
-verbalizat 3 liters if no drink liberal in flushing the
-ion contraindicatio amount of water bacteria and
-wbc: ns). toxins.
11,200
-Encourage the -assisted in sitz -Sitz baths may
use of a sitz bath and reduce perineal
bath. perilight. pain and
promotes muscle
relaxation.

-Instruct to -patient was -These food

avoid coffee, encouraged to items cause
tea, alcohol, avoid tea, coffee irritation to the
and sodas. urinary system
and should be
avoided.
-provide -syrup urilizer -Antispasmodic
prescribed and analgesic
was given.
analgesics. agents are
useful in
relieving
bladder
irritability,
spasm, and
pain.

41
ASSESS- NURSING GOAL PLAN OF IMPLEMEN - RATIONALE EVALUA
MENT DIAGNOSIs ACTION TATION TION
Subjective Hyperthermia Client will -Assess for .-patient body -Increased body The goal
data: related to maintain signs of was warm to temperature will was fully
Patient inflammation core increased body touch and had show a variety met as
said that as evidenced temperatur temperature. headache. of symptoms patient
I am by increase e within such as normal
feeling body normal sweating, body
cold and temperature range shivering, temperatur
shivering (101of) and within headache, warm e was
. warm to touch 2hrs. skin, and body maintaine
malaise. d i.e. 980f.
Objective
-Monitor vital
data: -temperature -To determine
signs,
-warm to 101of . appropriate
especially
touch temperature, as interventions.
-temperat indicated.
-ure
(101of) -Provide tepid -patient party -A tepid sponge
sponge bath. was assisted in bath is done to
sponging. reduce fever by
conduction and
convection.

-Encourage -patient was -To prevent the

adequate fluid given liberal occurrence of
intake. amount of fluids. dehydration.

-Maintain bed -adequate rest -To reduce

rest. was provided. metabolic
demands/oxyge
n consumption.
-Administer
antipyretic -tab Paracetamol -It reduces body
drugs as was given. temperature.
indicated.

42
ASSESS- NURSING GOAL PLAN OF IMPLEMEN - RATIONALE EVALUA
MENT DIAGNOSIs ACTION TATION TION
Subjective Impaired Client will -Assess the -patient voiding -Serve as a The goal
data: urinary achieve patients pattern was basis for was
Patient elimination normal pattern of assessed. determining achieved
said that related to urinary elimination. appropriate as the
I have frequent eliminatio interventions. patient
burning urination and n pattern, -Palpate the -patient bladder -To determine urgency
micturatio urgency as as clients bladder was palpated the presence of and
n and evidence by evidenced every 4 hours. every 4 hrs. urinary dysuria
frequently dysuria and by retention. was
urge to urge absence -Encourage -patient was -To help relieved.
urinate sign of increased fluid given plenty of improve renal
urinary intake (3-4 fluid. blood flow.
Objective disorders liters a day if
data: (urgency, tolerated).
urge, dysuria) -Encourage the -patient was -To prevent the
frequency within 1 client to void reminded to void accumulation of
day every 2-3 every 2-3 hrs. urine thus
hours. limiting the
number of
bacteria.
-Instruct the -patient was -Proper perineal
client to wipe taught to flush care helps in
the area from the perineum minimizing the
front to back . front to back. risk of
contamination
and re-
infection.

43
ASSESS- NURSING GOAL PLAN OF IMPLEMEN - RATIONALE EVALUA
MENT DIAGNOSIS ACTION TATION TION
objective Deficient Client will -Explain to the -patient was -Frequent The goal
data: knowledge verbalizes client about explained about recurrences of was met
recurrent related to knowledg UTI risk the risk factor, UTI may partially
UTI unfamiliarity e of factors, prevention, and indicate that the as patient
with nature causes and prevention, and treatment. client has no could
and treatment treatment treatment. understanding verbalize
of UTI as of UTI, of the disease to cause of
evidenced by controls and its UTI and
lack of risk management. ways of
awareness and factors, -Encourage the -patient was prevention
recurrent UTI. and client to finish encouraged to -Not finishing and
completes all prescribed complete the the antibiotic on manageme
medical antibiotics, prescribed dose. the prescribed nt.
treatment even if time will make
of UTI. symptoms the bacteria
resolve. grow and
multiply again.
-encourage -patient was
maintaining encouraged to -This will help
perineal maintain perineal in preventing
hygiene after a hygiene. the migration of
bowel the pathogen in
movement. the urethral
opening and, in
women, the
vaginal
opening.

-explain the -the importance -Completely

importance of of frequent emptying the
frequent bladder bladder
bladder emptying was prevents
emptying. explained. bladder
distention and
compromised
blood supply to
the bladder
wall. These
predispose the
client to UTI.

44
 -Such fabrics
-warn patient -patient was can accumulate
wearing tight- encourage to moisture and
fitting or wear cotton can provide an
constricting undergarments environment for
undergarments and loose bacterial
made of non- comfortable growth. Cotton
breathing clothes. fabric and loose
materials. fitting clotting
are more
encouraged.

-Periodic urine
-Need for cultures identify
follow-up the
urine cultures. effectiveness of
the
antimicrobial
therapy.

45
 DAILY PROGRESS NOTE

DATE VITALS SIGN REPORT

T P R BP
2074/2/21 101OF 80 2O 110/70 At 8 am female patient was received from ER
with diagnosis of 6th post partum day with
UTI. Patient came on wheelchair. Patient had
fever 101of. So cold sponging was done and
prescribed medication done. Urine c/s report
to collect on 2/23/2074.

2074/2/22 98 80 20` 110/70 Patient general condition was ill looking.

Morning care done. Peri-care and peri light
was provided. Patient was complaining of
headache. Prescribed medication done.
Patient had normal bowel movement but
burning micturation so encouraged to drink
plenty of fluids and frequently void to empty
bladder.

2074/2/23 98 80 20 120/80 Patient general condition looked improved.

Vitals sign were within normal limits.
Prescribed medication done. Health teaching
on personal hygiene, medication regimen and
follow up care was given.

2074/2/24 98 80 20 120/80 After urine C/S report patient was discharged

with another urine c/s sample. Follow up
with another c/s report.

46
 Health Teaching During hospitalization and during discharge

Health teaching during hospitalization play important role for the prompt recovery of
patient. So, I provided following teaching to the patient and her family:
Nutrition: Providing healthy and well balanced diet is most for the quick recovery of the
patient. I advised to have diet rich in protein, vitamin, iron,calcium and high fiber diet. I
encouraged to drink plenty of fluids (at least three to four glasses of water each day) to
help flush bacteria out of the urinary tract.

Personal hygiene:. Practice good personal hygiene. Always wipe from front to back.

- Prevention from infection Empty bladder completely as soon as you feel the urge, or at
least every three hours.
- Get plenty of vitamin C. It makes urine acidic and helps keep bacteria down. Vitamin C
is found in orange juice, citrus fruits, and broccoli.
- Wear cotton underwear. Bacteria grows better in moist places. Cotton does not trap
moisture.
- During intercourse, try different positions that cause less friction between your urethra
and your partners penis.
- Change sanitary pads and tampons frequently during menstruation.
- After intercourse, urinate as soon as possible. This will help flush out any bacteria that
may have gone into the urinary tract.

Reporting: Encourage the patient to report any unusual signs and symptoms that may
indicate recurrence of infection.

Bladder and bowel care: Encouraged to have high fiber diet and plenty of oral fluids to
prevent from constipation and regular bowel habit and watch for hematuria, dysuria.

Medicines: Patient was encouraged to complete the full medicine regimen and not to stop
by self.

Exclusive breastfeeding: Feed only breast milk without any additional food or drink, not
even water Breastfeeding on demand that is as often as the child wants, day and night
.No use of bottles, teats or pacifiers.

Immunization as per schedule

Appropriate family planning method.

47
 WHAT I LEARNT ROM THE CASE STUDY

It gives us comprehensive knowledge about a specific disease& relate with real situation. It is the
suitable way of applying theory in practice in real situation. Here are some points which I
learned from this case study.

About disease
I studied about this disease in depth by the resources available in, literatures, research,
internet and some journals. I also obtained information from doctor, sisters. I came to
know about the disease, its causes, signs & symptoms, diagnosis, differential diagnosis,
therapeutic management, nursing management, prognosis& got the chance to compare all
these with real case.

About patient
Through this case study I got the opportunity to know the history of patient, her
personal, family, social, educational as well as present & past health history, her habit,
way of living, ways of thinking and its influence on health and illness. I also got chance
to compare normal developmental task with the patient.

About family and environment

I also got the information about my patients family background, socio-cultural and
education background, concept about health and illness, nutrition, economic status,
religion, traditional beliefs and general attitude of family toward the disease and
treatment.
About nursing care
I applied holistic approach while proceeding nursing care to the patient, I also applied
theory of nursing while caring my patient.

About hospital policy

During my case study, I involved in every sector of activities admission to. I learnt about
the routine care performed in PNC ward, investigation procedures, medication policy like
supplies, different units, and available resources as well as the process of recording &
reporting. So I could know lots of rules and policy about the Paropakar Maternity and
womens Hospital, which was really very useful for me.

About proper documentation

Documentation is also the most important and useful skill. So through this case study my
skill of documenting was tremendously improved. I could formulate the case study
systematically and deeply.

48
 RESEARCH ARTICLE:

Prevalence of postpartum infections: a population-based observational study

Introduction:
We investigated the prevalence of postpartum infections among women giving birth during 1
year in a population-based observational/questionnaire study at seven hospitals in the southeast
region of Sweden.
Of the women >99% (n = 11 124) received a questionnaire to inquire if they had endometritis,
mastitis, or wound, urinary tract or any other infection within 2 months postpartum and whether
they received antibiotics for this.
Result:
Prevalence rates for infections and antibiotic treatment were estimated.
The response rate was 60.1%. At least one infectious episode was reported by 10.3% of the
women and 7.5% had received antibiotics. The prevalence for infections with and without
antibiotics were, respectively, mastitis 4.7% and 2.9%, urinary tract infection 3.0% and 2.4%,
endometritis 2.0% and 1.7%, wound infection 1.8% and 1.2%. There was no inter-county
difference in infection prevalence. Clinical postpartum infections in a high-resource setting are
relatively common.

49
 CONCLUSION

During our 6 weeks Maternity Practicum in Paropakar maternity and womens hospital,
everyone should take case study, document & present in comprehensive & systematic way
including definition, causes, pathophysiology, sign/symptoms, treatment & management in
comparative way & with real situation of patient. By this way I also got the chance to have case
study on Postpatum UTI. I gained lots of knowledge by comparing the case with patient. I
collected information from library, internet, doctors, ward sisters, laboratory examinations &
records and compared it with patient in real situation.

During my one week clinical posting in PNC ward, I provided holistic care to the patient and her
family,too considering physical, emotional, and economical & socio cultural aspect for her better
health and wellness. I also gained knowledge about the nursing theory & its application in real
situation. So, the case study not only gives the cognitive domain, but also provides us the
opportunity to develop psychomotor domain, which is very important in nursing field. So the
patient is the main source of converting knowledge in practice.

It also helped me to know a lot about the disease condition, its types, pathophysiology, cause,
treatment, management etc. I am glad to have this case as my case study.

Thus, I hereby conclude my case successfully as per the curriculum with the achievement of
much knowledge about the disease condition through both practical & theoretical basis. At last, I
want to say case study is very effective method of gaining knowledge & practice, so I always
want to appreciate it.

50
 REFERENCES:
HLMC( 2056). Textbook Of Adult Nursing, 1st Edition, Graphics Designers And
Printers, Health Learning Material Centre.
Jha R, JhaR(2006). J&J Health Science and Medical Surgical Nursing; 2nd Edition,
Makalu Publication.
Skidmore L, Roth (2009). Mosby`s Nursing Drug References; 25th Edition; Elsevier
India Pvt Ltd.
Smeltzer S.C (2009). Brunner &Suddharth's Textbook of Medical Surgical Nursing,
2nd edition, Wolter's Kluwer publication.
Hinkle J and Cheevar K(2014). Textbook of Medical Surgical Nursing, 13th edition,
Wolters Kluwer Health pvt. Ltd, New Dehli.
Doenac R., MoorhouseM.F(2007).Nursing Care Plans, 1st edition, Davis company
publication Ltd.
Myers Judith L and MG Glulanick(2003).Mosbys Nursing Care Plans, Elsevier Inc.
Williams L (2010). Manual Of Nursing Practice, 9th edition, Wolters Kluwer Pvt.
Ltd,New Delhi.
Basavanthapa B.T (2009).Medical Surgical Nursing, 2nd edition, Jaypee Publication.
Tuitui R. SuwalS.N (2001). Human Anatomy and Physiology, 8th edition,
VidyarthiPrakashan Pvt. Ltd.
Sharma M (2013).Nursing Concepts and Principles, 1st edition, Medhavi Publication,
Mahalaxmi Press, Baneshwor, Kathmandu.
Retrieved from:
o Schwartch MA, Wanz CG , Eckect LO, Cirtchlow CW, Risk factors for
urinary tract infection in the postpartum period, Volume 181, Issue 3,
Pages 547553
o Daniel Axelsson, Marie Blomberg, : 16 August 2014Full publication history
Prevalence of postpartum infections: a population-based observational study.
o P Thapa , K Parajuli , A Poudel , A Thapa , B Manandhar , D Laudari , HB
Malla , R Katiwada, Journal of Chitwan Medical College 2013; 3(4): 16-19
Available online at: www.jcmc.cmc.edu.np, CAUSATIVE AGENTS AND
SUSCEPTIBILITY OF ANTIMICROBIALS AMONG SUSPECTED FEMALES WITH URINARY
TRACT INFECTION IN TERTIARY CARE HOSPITALS OF WESTERN NEPAL , School of
Health and Allied Sciences, Pokhara University, Lekhnath, Kaski , Nepal. #
Equal Contribution as First Author.

51
 NATIONAL ACADEMY OF MEDICAL SCIENCES
BIR HOSPITAL NURSING CAMPUS
GAUSHALA, KATHMANDU
BACHLEOR IN NURSING SCIENCE

SUBMITTED TO: SUBMITTED BY:

MISS. JANAKI DHAMI RUJA SHAKYA
NURSING INSTRUCTOR BNS 2ND YEAR
BHNC ROLL NO.24
BHNC

52
53