Case Study

Name: Pamate, Zamiera T. Date: August 22, 2017

Year and Section: BSN III-C NCM 103

Case Scenario:

Ms. Abdulla, a 24 year old, reports that for the last four weeks, she has been constantly going to the bathroom
to urinate, and has experiencing a burning sensation whenever she urinates. She also experience a fever of
39.8c. She also stated she has to go to the bathroom every hour or two; in addition, she states that her urine
has a very strong odor which is different than anything she has ever noticed. She then suspected to have UTI
and wonders if the infection may have been caused by the fact that she has switched methods of birth control
so that she has been using a diaphragm for about five or six weeks. She has tried drinking cranberry juice, which
was suggested to her by a family member, in order to get rid of the problem, but has only found that as time
goes on, it seems to get worse.

The patient reports that she has only had a urinary tract infection once before, about four years ago, and it
followed a bout with severe diarrhea; her doctor suggested that bacteria from her rectal area had entered the
vagina, leading to the infection. At that time, she was treated with a 10 day course of antibiotics, and the
infection seemed to clear up almost immediately.

I. CLIENTS PROFILE:

Name: Zhara Abdulla

Age: 24 years old
Sex: Female
Address: Tetuan, Zamboanga City
Date of birth: March 17, 1992
Place of birth: Zamboanga City
Religion: Islam
Occupation: Businesswoman
Diagnosis: Urinary Tract Infection

Physician: Dr. Z. Dela Cruz

Patient in by: August 22, 2017
Admission no. : 0621
II. REVIEW OF SYSTEMS/PHYSICAL EXAMINATION:

REVIEW OF SYSTEM PHYSICAL EXAMINATION

A. General / Overall health status > received patient conscious, awake and coherent
lying on bed
> with IVF of D5LR 500ml @ 30gtts/min infusing
well
> RR = 24 bpm
> PR = 138 bpm
> Temp = 38.4C
> (+) weakness
> (-) productive cough
B. Integument Skin

> Inspection
- brown skin color
- good skin turgor
- (-) scaling
- (-) cyanosis
- (-) edema
- (-) dryness
> Palpation
- (+) smooth and flabby skin
- (-) edema

Hair
> Inspection
- black hair evenly distributed
- wavy hair
- (-) dandruff

Nails
> Inspection
- clean, well-trimmed nails
- pink nail beds
- (-) clubbing of fingers
> Palpation
- smooth on surfaces
- skin warm to touch
C. Head > Inspection
- normocephalic
- bilaterally symmetric
- (-) lesions
>Palpation
- (+) smooth surface
D. Eyes > Inspection
- bilaterally symmetrical
- iris round, dark brown in color
- eyeballs moist and glossy
 - (+) PERRLA
- (+) pinkish upper and lower conjunctiva
E. Ears > Inspection
- bilaterally symmetrical
- (-)swelling
- (-) lesions
- (-) discharges
- (-) impaired hearing
> Palpation
- pinna recoils after it is folded
F. Nose and Sinuses > Inspection
- bilaterally symmetrical
- nasal septum at midline
- no deformities
- (-) colds
- (-) swelling
- (-) lesions
- (-) epistaxis
- (-) nasal flaring

G. Mouth and Throat Lips

> Inspection
- symmetrical lips
- pinkish lip color
- (+) dry lips
Mouth
> Inspection
- pinkish gum color
- tongue in the midline
H. Neck > Inspection
- (+) bounding carotid artery
- (-) lesions
- (-) inflammation
> Palpation
- trachea at midline
- (-) swollen lymph nodes
I.Neurologic > Inspection
- Loc: Conscious and Coherent
J.Lymphatic >Palpation
- No palpable lymph nodes
 L. Respiratory
M. Cardiovascular
N. Gastrointestinal
O. Urinary
III. HEALTH PROMOTION AND MAINTENANCE ACTIVITY
Personal Habit
o Use of Tobacco
o Alcohol
o Prohibited Drugs
o OTC and Prescribed medicine
o Hygiene
o Elimination Pattern
> Inspection
- use of accessory muscles in breathing
- (-) noisy breathing
- (-) shallow respirations
- RR = 24 bpm
- (-) cough
- (-) productive cough
> Palpation
- bilateral chest expansion
> Auscultation
- (-) crackles
> Inspection
- (-) cyanosis
- (-) edema
- (-) varicose veins on the legs
> Palpation
- PR = 87 bpm
> Auscultation
- (-) irregular heart rhythm
> Inspection
- umbilicus in midline
- skin color even with chest color
- (+) yellowish to light brownish stool
- (+) nausea and vomiting
>Percussion
- Hyper Resonant
> Auscultation
- normoactive bowel sounds
>Palpation
- No tenderness
> Inspection
- urine color is dark yellow
- urine appears cloudy
- has a strong odor
- client doesnt use tobacco
- client doesnt drink alcohol
- client doesnt use prohibited drugs
- client drinks her vitamins
- client takes a bath 2-3 times/day
- client has a regular urination before and defecation
 Sleep and Wake Pattern
Client usually wakes up at 4:00am in the morning to get ready for work.
Exercise and Activity
Her usual activity is playing badminton or table tennis whenever she has free time.
Recreation
She usually reads books and watches television. Sometimes goes to the mall for window shopping.
Nutrition
She usually eats a lot of protein rich foods (meat, fish) and counts the calories she takes.
Stress and Coping Pattern
She stated that whenever shes stress she goes to the cinema to watch movies or eats pizza.
Socio-Economic status
Financial Status She earn 10,000-15,000php a month.

IV. DISEASE OVERVIEW

A urinary tract infection (UTI) is an infection involving the kidneys, ureters, bladder, or urethra. These are the
structures that urine passes through before being eliminated from the body.

The kidneys are a pair of small organs that

lie on either side of the spine at about
waist level. They have several important
functions in the body, including removing
waste and excess water from the blood
and eliminating them as urine. These
functions make them important in the
regulation of blood pressure. Kidneys are
also very sensitive to changes in blood sugar levels and blood pressure and electrolyte balance. Both diabetes
and hypertension can cause damage to these organs.

Two ureters, narrow tubes about 10 inches long, drain urine from each kidney into the bladder.
 The bladder is a small saclike organ that collects and stores urine. When the urine reaches a certain level
in the bladder, we experience the sensation that we have to void, then the muscle lining the bladder can
be voluntarily contracted to expel the urine.

The urethra is a small tube connecting the bladder with the outside of the body. A muscle called the
urinary sphincter, located at the junction of the bladder and the urethra, must relax at the same time
the bladder contracts to expel urine.

Any part of this system can become infected. As a rule, the farther up in the urinary tract the infection is located,
the more serious it is.

Anatomy and Physiology:

How does the urinary system work?

The body takes nutrients from food and converts them to energy.
After the body has taken the food that it needs, waste products
are left behind in the bowel and in the blood.

The urinary system keeps the chemicals and water in balance by

removing a type of waste, called urea, from the blood. Urea is
produced when foods containing protein, such as meat, poultry,
and certain vegetables, are broken down in the body. Urea is
carried in the bloodstream to the kidneys.

Urinary system parts and their functions:

Two kidneys - a pair of purplish-brown organs located below
the ribs toward the middle of the back. Their function is to:

Remove liquid waste from the blood in the form of urine.

Keep a stable balance of salts and other substances in the

blood.

Produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron
consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal
tubule. Urea, together with water and other waste substances, forms the urine as it passes through the
nephrons and down the renal tubules of the kidney.

Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls
continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is
 allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of
urine are emptied into the bladder from the ureters.
Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments
that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store
urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can
store up to two cups of urine for two to five hours.

Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber
band around the opening of the bladder.

Nerves in the bladder -alert a person when it is time to urinate, or empty the bladder.

Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to
tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter
muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the
correct order, normal urination occurs.

IV. PATHOPHYSIOLOGY OF UTI

For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the
urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate
inflammation. Most UTIs result from fecal organisms that ascend from the perineum to the urethra and the
bladder and then adhere to the mucosal surfaces.

Bacterial Invasion of the Urinary Tract

By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder
can clear itself of even large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally
exerts a no adherent protective effect against various bacteria. The GAG molecule attracts water molecules,
forming water barrier that serves as defensive layer between the bladder and the urine. GAG may be impaired
by certain agents (cyclamate, saccharin, aspartame, and trytophan metabolites). The normal bacterial flora of
the vagina and urethral area also interfere with adherence of Escherichia coli (the most common
microorganisms causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to
bacteria.

Reflux

An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward
flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure
rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine
flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra.
urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and
urethral closure pressure may be altered with menopause, increasing the incidence of infection in
postmenopausal women. Reflux is most often noted, however, in young children. Treatment is based on its
severity.
 Ureterovesical or vesicoureteral reflux refers to the backflow of urine from the bladder into one or both
ureters. Normally, the ureteroveical junction prevents urine from traveling back into the urether. The ureters
tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during
normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the
bacteria may reach and eventually destroy the kidney

Schematic Diagram:

Loss of integrity of the mucosal lining (caused by in indwelling catheter, tumor, parasites, or calculus)

Decreased resistance to invading organisms

Inflammatory changes occur in the affected portion of the Urinary tract.

Clumps of bacteria may be present.

Inflammatory changes in the renal pelvis and throughout the kidney.

Scarring of the kidney parenchyma (occurs in chronic infection), which interferes kidney function.

Etiology:

Causative organism:
- Escherichia Coli 90% of UTI in women.
- Enterocobacter
- Pseudomonas
- Staphylococcus saprophyticus
- Candida

Route of entry:
- Ascent from the urethra (most common)
- Circulating blood.

Contributing causes:
obstruction usually congenital
vesicoureteral reflux
infections elsewhere in the body
1.) upper respiratory
2.) gastrointestinal diarrhea
poor perineal hygiene
short female urethra
catheterization
Inherent defect in the ability of the bladder mucosa to protect it from microbial infection.