INTRODUCTION

Patient LGC, an eight year old girl was admitted to Cagayan de Oro Maternity-
Children’s Hospital and Puereculture Center last January 9, 2010 at 9:10 pm with chief
complaints of fever and vomiting. To days prior to admission, patient experienced
dysuria, moderate grade fever associated with 3 episodes of vomiting. Patient was
previously admitted to PolyMedic Hospital last June 2009 with dengue. After laboratory
examination, patient was diagnosed with Urinary Tract Infection.

Urinary tract infection is typically confirmed on the basis of a certain number of

microorganisms in the urinary system, although manifestations may begin with many
fewer microorganisms. The infectious process usually affects the bladder, but the urethra,
ureters, and the kidneys may be involved. Cystitis is the common type of UTI, is an
inflammation of the bladder wall, usually caused by ascending bacteria or obstructive
voiding patterns that lead to decreased flow or stasis of urine. Urethritis, inflammation of
the urethra, may cause the same manifestations as cystitis.

UTI is on of the most common infection treated by primary care providers.

Untreated, it has the potential for serious consequences, such as pyelonephritis or
inflammation of the kidneys and bacteremia or bacteria in the blood. On rare occasions,
complications of UTI can lead to death.

The prevalence of UTI is about eight times higher in women than in men,
probably because the female urethra is shorter and lies closer the anal and vaginal
openings. This position increases the risk of bacterial contamination of the lower urinary
tract. About 6 to 7 million young women see physicians for UTIs each year, second in
frequency only to upper respiratory infections. In 5% to !0% of cases, the UTI recurs
after initial treatment.

UTIs rarely develop in men younger than 50 years because of the length of the
male urethra and the antibacterial properties of the prostatic fluid. The incidence of UTIs
in men increases with age, as does the incidence of prostatic disease. This medical
problem leads to dysfunctional voiding patterns with incomplete emptying of the bladder.
Stasis of the urine in the bladder increases the risk of cystitis. The incidence of UTI
increases with hospitalization, usually from catheterization procedures and possibly from
inadequate catheter care. Nosocomial UTIs occur in about 2% inpatients. About 1% of
nosocomial UTIs (500 each year) become life threatening. Catheter-associated urinary
tract infections account for about 40% of all nosocomial infections and increase the
duration of hospital stay, the cost, and mortality risk.

The most common UTI-causing bacteria are the gram negative organisms found
in the intestine. Escherichia coli probably cause about 80% of UTIs, and Klebsiella
causes about 5% of reported UTIs. Enterobacter and Proteus are found in about 2% of
reported cases.

1
 Women with vaginal candidiasis commonly complain if UTI manifestations.
Other causative organisms, such as Chlamydia trachomatis, Trichomonas vaginalis,
Neisseria gonorrhoeae, and herpes simplex, may be responsible for UTI manifestations as
well.
Other risk factors include sexual intercourse, pregnancy, poor hygiene, dysfunctional
voiding patterns, or history of female genital mutilation. Hormonal changes in pregnant
and postmenopausal women alter the vaginal pH, change the vaginal flora, and may
allow abnormal levels of bacteria to grow. A poorly fitting contraceptive diaphragm may
lead to recurrent UTI as well. Pressure against the urethra may obstruct the flow of urine,
leading to irritation and incomplete emptying of the bladder. Diabetic clients are at risk
for UTIs because increasing neuropathy can keep the bladder from emptying completely.

A. GENERAL OBJECTIVES

This paper aims to present an explanation of the physiologic events that take place in
the human body during the course of the disease condition (Urinary Tract Infection).
Also, it aims to present a concept map of the disease itself together with appropriate
nursing and medical interventions that would help the patient cope and overcome her
condition. Furthermore, this case study hopes to provide rational measures that could help
prevent the acquisition of the disease mentioned above and to present the common
nursing diagnosis that the client manifested and will manifest if not given adequate
intervention.

B. SPECIFIC OBJECTIVES
After 2 hours of oral case presentation, the group will be able to :
1. Present the gathered data and information using complete assessment tool.
2. Discuss the anatomy and physiology involved in the condition of our patient.
3. Present the pathophysiology of the patient’s condition, including possible
complication, signs and symptoms, medical treatment and diagnostic procedures .
4. Present identified nursing problems basing from the patient’s actual
manifestations, and discuss the plan of care specific for the client’s needs.
5. Present the health teachings given to the patient’s parents with regards to the
cause and effects of her condition.

Scope and Limitation

This case study focuses to a pediatric patient, who has been diagnosed to have
Urinary Tract Infection and is currently confined in Cagayan de Oro Maternity-
Children’s Hospital and Puereculture Center, pedia ward.
The scope of this case study covers the patient’s health history, the diagnostic
examinations as indicated by her attending physician, medical and nursing management.
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The nursing diagnoses were also identified based from the assessment data gathered and
suitable interventions were instituted to return the patient to her optimal level of
functioning. In addition, the proponents of this case study are also limited to the hours
being rendered to the patient from January 11, 2010 to January 12, 2010.
This case study is limited to the information being collected the patient and from
her personal chart. The objectives and subjective data gathering is only limited in the
hospital premises. Interpretation of the diagnostic test is only limited to rating it as low,
high or normal based from the normal values indicated for each test..
On the other hand, the formulation of the nursing care plans were based on the
problems experienced by the patient and was limited only to the duty hours rendered by
the group. Prioritizing the nursing care plan focuses only on the patient alone. Alongside
with this, criteria for prioritizing the nursing care plan was based on the Maslow’s
hierarchy of needs as well ABC (airway, breathing, circulation) pattern in order to render
a safe and quality nursing care to the patient.

ASSESSMENT

GENERAL INFORMATION
Name: LGC Age: 8 years old
Birthday: July 31, 2001 Civil Status: single
Sex: Female Religion: Catholic
Address: Palmera Drive Tibasak, CDO
Informant: LC Relation: Mother
Admission Date: January 9, 2010
Attending Physician: Dr. Macapasir
Chief Complaint: fever and vomiting
Diagnosis/Impression: Urinary Tract Infection
History of Present Ilness: Morning PTA – sudden on sent of moderate grade fever
associated with 3 episodes of vomiting
Vital Signs:
HR: 84bpm RR: 14cpm Temp: 38.5 C
BP: 110/80mmHg
Weight: 32kgs

ACTIVITY AND REST

Numbers of hours of sleep: 8-9 hours

Naps: seldom, 1-2 hours
Difficulty in sleeping: None
Feeling of awakening: yes, esp. when the client have the urge to urinate at night during
asleep.
Comment: before the admission and sickness the patient had no problem in sleeping but
due to the condition and hospitalization the patient reported decreased amount of sleep
(5-7 hrs.) and rest and have a feeling of awakening during night due to the urge to urinate

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CIRCULATION
Extremities temperature : warm and flushing noted
Color of Nail Beds: pale
Lips: dry and cracked
Mucous Membrane: pale and dry

ELIMINATION
Subjective:
Usual voiding pattern: from 4-6 times
Pain/burning/difficulties in voiding: burning sensation when urinating
Others/Comments: The Mother verbalized a change in the voiding pattern of her
daughter from the usual 4-6 times to 8-10 times per day in a scanty amounts.

FOOD/FLUID
Subjective
# of meals per day: 4-5 times/day
Last Meal/Intake: rice and fried pork during lunch
N/V: patient vomited 3 times prior to admission and vomited 7 times last 1/10/10
Allergies/Food Intolerance: patient is allergic to egg and seafoods
Weight: 32kgs Usual: 33-34 kgs
Changes: patient lose weight from 33kgs to 32 kgs.

PAIN/COMFORT

Subjective
Onset: January 8, 2010 Duration: 20-30 minutes
Location: hypogastrium and urethra
Frequency: 8-10 times/day or upon urination
Intensity: (1-10): 6/10
Quality: moderate pain

Description of pain (Check all that apply)

()Shooting
()Stabbing
()Gnawing
()Sharp
(/)Dull
()Aching
()Numb
()Throbbing
()Radiating
(/)Burning

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 ()Unbearable
Precipitating factors: UTI
Aggravating factors: bladder retention and urination
How relieved: rest
Associated symptoms: fever

Objective (check all that apply)

()Grimacing
()Being Irritable
()Moaning
()Sitting rigidly
(/)Sighing
()Moving very slowly
()Limping
()clenching teeth
()Avoiding physical act
(/)Lying down during the day
()Requesting Help with walking
()Stopping frequently while walking
()Walking with abnormal gait
()Frequently shifting posture or position
()Moving in unguarded or protected manner
()Holding or supporting the painful body area
()Asking to be relieved from tasks/activities
()Asking such questions as “Why did this happen to me?”
()Using a cane, cervical collar or other prosthetic devices

Familial risk factors(check all that apply & indicate relationship)

( ) Diabetes none
( ) TB none
( ) Heart disease none
( ) Stroke none
( ) High BP none
( ) Epilepsy none
(/) Kidney disease Aunt
( ) Cancer none
( ) Mental illness none

Diagnostic and laboratory results

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Complete Blood Count - January 9, 2010

RESULT NORMAL INTERPRETATION

VALUE
Hgb 152 gL 23-153 NORMAL
Hct 0.36 .36 NORMAL
RBC 5.19 Thou 4-6 Thou NORMAL
WBC 12 Thou 4.5-10 Thou INCREASED
DIFFERENTIAL
COUNT
NEUTROPHIL 0.76 0.50-0.70 INCREASED
LYMPHOCYTES 0.23 0.20-0.40 NORMAL
EOSINOPHIL 0.00 0-0.05 NORMAL
MONOCYTES 0.01 0-0.01 NORMAL
BASOPHILS 0.00 0-0.01 NORMAL
PLATELETS 260 150-400 NORMAL

URINALYSIS - January 9, 2010

PHYSICAL CHARACTERISTICS:

COLOR: YELLOW
TRANSPERENCY: SLIGHTLY HAZY

CHEMICAL TESTS:

pH: 6.5 SG: 1.010

SUGAR: NEGATIVE ALBUMIN: NEGATIVE

CELLS:

PUS CELLS: 4-6/HPF

REDBLOOD CELLS: 4-6/HPF
SQUAMOUS CELLS: OCCASIONAL

Anatomy and Physiology of Renal System

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 The Renal System (also called Urinary/excretory system or the
genitourinary system) is the organ system that produces, stores, and eliminates
urine. It includes two kidneys, two ureters, the bladder, the urethra, and the penis
in males.

Kidney

The kidneys are located behind the abdominal cavity, in a space called the
retroperitoneum. There are two, one on each side of the spine; they are
approximately at the vertebral level T12 to L3. The right kidney sits just below the
diaphragm and posterior to the liver, the left below the diaphragm and posterior
to the spleen. Resting on top of each kidney is an adrenal gland (also called the
suprarenal gland). The asymmetry within the abdominal cavity caused by the
liver typically results in the right kidney being slightly lower than the left, and left
kidney being located slightly more medial than the right. The upper (cranial) parts
of the kidneys are partially protected by the eleventh and twelfth ribs, and each

7
whole kidney and adrenal gland are surrounded by two layers of fat (the perirenal
and pararenal fat) and the renal fascia. Each adult kidney weighs between 125
and 170 g in males and between 115 and 155 g in females. The left kidney is
typically slightly larger than the right.

The kidney has a bean-shaped structure; each kidney has concave and convex
surfaces. The concave surface, the renal hilum, is the point at which the renal
artery enters the organ, and the renal vein and ureter leave. The kidney is
surrounded by tough fibrous tissue, the renal capsule, which is itself surrounded
by perinephric fat, renal fascia and paranephric fat. The anterior (front) border of
these tissues is the peritoneum, while the posterior (rear) border is the
transversalis fascia.

The superior border of the right kidney is adjacent to the liver; and the spleen, for
the left border. So, both, move down on inspiration.

The substance, or parenchyma, of the kidney is divided into two major structures:
superficial is the renal cortex and deep is the renal medulla. Grossly, these
structures take the shape of 8 to 18 cone-shaped renal lobes, each containing
renal cortex surrounding a portion of medulla called a renal pyramid (of Malpighi).
Between the renal pyramids are projections of cortex called renal columns.
Nephrons, the urine-producing functional structures of the kidney, span the
cortex and medulla. The initial filtering portion of a nephron is the renal
corpuscle, located in the cortex, which is followed by a renal tubule that passes
from the cortex deep into the medullary pyramids. Part of the renal cortex, a
medullary ray is a collection of renal tubules that drain into a single collecting
duct.

The tip, or papilla, of each pyramid empties urine into a minor calyx, minor
calyces empty into major calyces, and major calyces empty into the renal pelvis,
which becomes the ureter.

The kidneys receive blood from the renal arteries, left and right, which
branch directly from the abdominal aorta. Despite their relatively small size, the
kidneys receive approximately 20% of the cardiac output.

Each renal artery branches into segmental arteries, dividing further into interlobar
arteries which penetrate the renal capsule and extend through the renal columns
between the renal pyramids. The interlobar arteries then supply blood to the
arcuate arteries that run through the boundary of the cortex and the medulla.
Each arcuate artery supplies several interlobular arteries that feed into the
afferent arterioles that supply the glomeruli.

After filtration occurs the blood moves through a small network of venules that
converge into interlobular veins. As with the arteriole distribution the veins follow
the same pattern, the interlobular provide blood to the arcuate veins then back to

8
the interlobar veins which come to form the renal vein exiting the kidney for
transfusion for blood.

Ureter

The ureters are muscular ducts that propel urine from the kidneys to the urinary
bladder. In the adult, the ureters are usually 25–30 cm (10–12 in) long.

The ureters arise from the renal pelvis on the medial aspect of each kidney
before descending towards the bladder on the front of the psoas major muscle.
The ureters cross the pelvic brim near the bifurcation of the iliac arteries (which
they run over). This "pelviureteric junction" is a common site for the impaction of
kidney stones (the other being the uterovesical valve). The ureters run
posteroinferior on the lateral walls of the pelvis they then curve anteriormedial to
enter the bladder through the back, at the vesicoureteric junction, running within
the wall of the bladder for a few centimeters. The backflow of urine is prevented
by valves known as ureterovesical valves. In the female, the ureters pass
through the mesometrium on the way to the urinary bladder.

Urinary Bladder

The urinary bladder is the organ that collects urine excreted by the
kidneys prior to disposal by urination. A hollow muscular, and distensible (or
elastic) organ, the bladder sits on the pelvic floor. Urine enters the bladder via the
ureters and exits via the urethra.

Embryologically, the bladder is derived from the urogenital sinus and, it is

initially continuous with the allantois. In males, the base of the bladder lies
between the rectum and the pubic symphysis. It is superior to the prostate, and
separated from the rectum by the rectovesical excavation. In females, the
bladder sits inferior to the uterus and anterior to the vagina. It is separated from
the uterus by the vesicouterine excavation. In infants and young children, the
urinary bladder is in the abdomen even when empty.

Urethra

zz

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The endpoint of the urinary system is the urethra. Typically the urethra is
colonized by commensal bacteria below the external urethral sphincter.
The urethra emerges from the end of the penis in males and between the
clitoris and the vagina in females.

In anatomy, the urethra (from Greek οὐρήθρα - ourethra) is a tube which

connects the urinary bladder to the outside of the body. The urethra has an
excretory function in both sexes to pass urine. In males, the urethra travels
through the penis, and carries semen as well as urine. In females, the urethra is
shorter and emerges above the vaginal opening.The external urethral sphincter
is a striated muscle that allows voluntary control over urine.

Renal Physiology

Renal physiology (Latin rēnēs, "kidney") is the study of the physiology of

the kidney. This encompasses all functions of the kidney, including reabsorption
of glucose, amino acids, and other small molecules; regulation of sodium,
potassium, and other electrolytes; regulation of fluid balance and blood pressure;
maintenance of acid-base balance; and the production of various hormones
including erythropoietin and vitamin D.

The kidney also participates in whole-body homeostasis, regulating acid-

base balance, electrolyte concentrations, extracellular fluid volume, and
regulation of blood pressure. The kidney accomplishes these homeostatic
functions both independently and in concert with other organs, particularly those
of the endocrine system. Various endocrine hormones coordinate these
endocrine functions; these include renin, angiotensin II, aldosterone, antidiuretic
hormone, and atrial natriuretic peptide, among others.

Much of renal physiology is studied at the level of the nephron, the smallest
functional unit of the kidney. Each nephron begins with a filtration component that
filters blood entering the kidney. These filtrate then flows along the length of the
nephron, which is a tubular structure lined by a single layer of specialized cells
and surrounded by capillaries. The major functions of these lining cells are the

10
reabsorption of water and small molecules from the filtrate into the blood, and the
secretion of wastes from the blood into the urine.

Proper function of the kidney requires that it receives and adequately filters
blood. This is performed at the microscopic level by many hundreds of thousands
of filtration units called renal corpuscles, each of which is composed of a
glomerulus and a Bowman's capsule. A global assessment of renal function is
often ascertained by estimating the rate of filtration, called the glomerular
filtration rate (GFR).

Many of the kidney's functions are accomplished by relatively simple

mechanisms of filtration, reabsorption, and secretion, which take place in the
nephron. Filtration, which takes place at the renal corpuscle, is the process by
which cells and large proteins are filtered from the blood to make an ultrafiltrate
that will eventually become urine. Reabsorption is the transport of molecules
from this ultrafiltrate and into the blood. Secretion is the reverse process, in
which molecules are transported in the opposite direction, from the blood into the
urine.

Mechanisms:

The kidney's ability to perform many of its functions depends on the three
fundamental functions of filtration, reabsorption, and secretion.

Filtration

The blood is filtered by nephrons, the functional units of the kidney. Each
nephron begins in a renal corpuscle, which is composed of a glomerulus
enclosed in a Bowman's capsule. Cells, proteins, and other large molecules are
filtered out of the glomerulus by a process of ultrafiltration, leaving an ultrafiltrate
that resembles plasma (except that the ultrafiltrate has negligible plasma
proteins) to enter Bowman's space. Filtration is driven by Starling forces.

The ultrafiltrate is passed through, in turn, the proximal tubule, the loop of Henle,
the distal convoluted tubule, and a series of collecting ducts to form urine.

Reabsorption

Tubular reabsorption is the process by which solutes and water are removed
from the tubular fluid and transported into the blood. It is called reabsorption (and
not absorption) because these substances have already been absorbed once
(particularly in the intestines).

Reabsorption is a two-step process beginning with the active or passive

extraction of substances from the tubule fluid into the renal interstitium (the
connective tissue that surrounds the nephrons), and then the transport of these

11
substances from the interstitium into the bloodstream. These transport processes
are driven by Starling forces, diffusion, and active transport.

Indirect reabsorption

In some cases, reabsorption is indirect. For example, bicarbonate (HCO3-) does

not have a transporter, so its reabsorption involves a series of reactions in the
tubule lumen and tubular epithelium. It begins with the active secretion of a
hydrogen ion (H+) into the tubule fluid via a Na/H exchanger:

• In the lumen
o The H+ combines with HCO3- to form carbonic acid (H2CO3)
o Luminal carbonic anhydrase enzymatically converts H2CO3 into H2O
and CO2
o CO2 freely diffuses into the cell
• In the epithelial cell
o Cytoplasmic carbonic anhydrase converts the CO2 and H2O (which
is abundant in the cell) into H2CO3
o H2CO3 readily dissociates into H+ and HCO3-
o HCO3- is facilitated out of the cell's basolateral membrane

Secretion

Tubular secretion is the transfer of materials from peritubular capillaries to renal

tubular lumen. Tubular secretion is caused mainly by active transport.

Usually only a few substances are secreted. These substances are present in
great excess or are natural poisons.

Many drugs are eliminated by tubular secretion.

Excretion of Waste

The kidneys excrete a variety of waste products produced by metabolism. These

include the nitrogenous wastes urea, from protein catabolism, and uric acid, from
nucleic acid metabolism.

Acid-base homeostasis

The kidneys are also responsible in maintaining acid-base homeostasis, which is

the maintenance of pH around a relatively stable value. The kidneys contribute to
acid-base homeostasis by regulating bicarbonate (HCO3-) concentration.

12
Osmolality regulation

Any significant rise or drop in plasma osmolality is detected by the hypothalamus,

which communicates directly with the posterior pituitary gland. A rise in
osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in
water reabsorption by the kidney and an increase in urine concentration. The two
factors work together to return the plasma osmolality to its normal levels.

ADH binds to principal cells in the collecting duct that translocate aquaporins to
the membrane allowing water to leave the normally impermeable membrane and
be reabsorbed into the body by the vasa recta, thus increasing the plasma
volume of the body.

There are two systems that create a hyperosmotic medulla and thus increase the
body plasma volume: Urea recycling and the 'single effect.'

Urea is usually excreted as a waste product from the kidneys. However, when
plasma blood volume is low and ADH is released the aquaporins that are opened
are also permeable to urea. This allows urea to leave the collecting duct into the
medulla creating a hyperosmotic solution that 'attracts' water. Urea can then re-
enter the nephron and be excreted or recycled again depending on whether ADH
is still present or not.

The 'Single effect' describes the fact that the ascending thick limb of the loop of
Henle is not permeable to water but is permeable to NaCl. This means that a
countercurrent system is created whereby the medulla becomes increasingly
concentrated setting up an osmotic gradient for water to follow should the
aquaporins of the collecting duct be opened by ADH.

Blood pressure regulation

Long-term regulation of blood pressure predominantly depends upon the

kidney. This primarily occurs through maintenance of the extracellular
fluid compartment, the size of which depends on the plasma sodium
concentration. Although the kidney cannot directly sense blood pressure,
changes in the delivery of sodium and chloride to the distal part of the
nephron alter the kidney's secretion of the enzyme renin. When the
extracellular fluid compartment is expanded and blood pressure is high,
the delivery of these ions is increased and renin secretion is decreased.
Similarly, when the extracellular fluid compartment is contracted and blood
pressure is low, sodium and chloride delivery is decreased and renin
secretion is increased in response.

Renin is the first in a series of important chemical messengers that comprise the
renin-angiotensin system. Changes in renin ultimately alter the output of this
system, principally the hormones angiotensin II and aldosterone. Each hormone

13
acts via multiple mechanisms, but both increase the kidney's absorption of
sodium chloride, thereby expanding the extracellular fluid compartment and
raising blood pressure. When renin levels are elevated, the concentrations of
angiotensin II and aldosterone increase, leading to increased sodium chloride
reabsorption, expansion of the extracellular fluid compartment, and an increase
in blood pressure. Conversely, when renin levels are low, angiotensin II and
aldosterone levels decrease, contracting the extracellular fluid compartment, and
decreasing blood pressure.

Hormone secretion

The kidneys secrete a variety of hormones, including erythropoietin, calcitriol,

and renin. Erythropoietin is released in response to hypoxia (low levels of
oxygen) in the renal circulation. It stimulates erythropoiesis (production of red
blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D,
promotes intestinal absorption of calcium and the renal excretion of phosphate.
Part of the renin-angiotensin-aldosterone system, renin is an enzyme involved in
the regulation of aldosterone levels.

Some key regulatory hormones for reabsorption include:

• aldosterone, which stimulates active sodium reabsorption (and water as a

result)
• antidiuretic hormone, which stimulates passive water reabsorption

Both hormones exert their effects principally on the collecting ducts.

Secretion of other hormones:

• Secretion of erythropoietin, which regulates red blood cell production in

the bone marrow.
• Secretion of renin, which is a key part of the renin-angiotensin-aldosterone
system. (Technically, though, renin is not a hormone, it is an enzyme.)
• Secretion of the active form of vitamin D (calcitriol) and prostaglandins.

PATHOPYSIOLOGY- Narrative

Bacterial adherence to mucosal cells is widely accepted prerequisite to

colonization and infection of mucosal surfaces including the urinary tract (Eden et al.,
1997). The interaction of the mucosal cell and the bacterium is probably dependent on
receptors on the mucosal cells and some type of attachment mechanism employed by the
bacteria. Several host receptors have been identified, with mannose being linked to
cystitis, and the P blood group antigen to pyelonephritis. Bacteria, too, have special types
of surface structures that they utilize as adhesions. These bacterial fimbrae, or pili, may

14
be present in large numbers on bacterial cells (Parsons, 1986). Fowler and Stamey (1977
and 1978) showed a possible increased adherence to the cells of cystitis prone females,
suggesting that both host and bacteria play important roles in the adherence process.
However, whether this host-bacteria interaction leads to asymptomatic bateriuria, or
tissue invasion causing symptomatic bacteriuria, depends on the intactness of the host
defense mechanisms within the urinary tract.
In the normal bladder there is resistance to infection from microorganisms in
general. This is due to the ladder’s intrinsic defense mechanisms (1) the bacteriostatic
property of urine to most common urinary pathogens, (2) dilution of the bacterial
inoculum and effective urine “wash-out factor” with voiding, and (3) an intact bladder
mucosal surface. However, structural and functional abnormalities of the urinary tract
may interfere with these defense mechanisms and increase the risk of infection. When an
inflammatory process does ensue, it usually involves only the mucosa and submucosa
layers.
Chronic cystitis refers to recurrent episodes of cystitis. The women who develop
recurrent cystitis differ from normal women in that they tend to carry an increased
number of abnormal organisms on their vaginal vestibules, increasing their risk of
another UTI. The cause of chronic cystitis in these women appears to be a lack of some
form of local defense mechanism, which allows the colonization of bacteria in the vaginal
vestibule. With men, chronic bacterial prostatitis is the most common cause of the
chronic cystitis.

15
16
Medical management
Management of UTIs typically involves drug therapy and patients education. The nurse is
a key figure in teaching the patient about medication regimens and infection prevention
measures.
Patients in institutional settings may require 7 to 10 days of medication for the
treatment to be effective. Controversy continues about the need for treatment of
asymptomatic bacteriuria in the institutionalized elderly patients because resulting
antibiotic-resistant organisms and sepsis maybe greater threats to the patient. Most
experts now recommend withholding antibiotics unless symptoms develop. Treatment
regimens, however, are generally the same as those for younger adults, although age-
related changes in intestinal absorption of medications and decreased renal function and
hepatic flow may necessitate alterations in the antimicrobial regimen. Renal function
must be monitored and the dosage of medications altered accordingly.

Acute Pharmacologic Therapy

The ideal treatment of UTI is an antimicrobial agent that effectively eradicates bacteria
from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing
the incidence of vaginal yeast infections. Additionally, the antimicrobial agent should be
affordable and should produce few side effects and low resistance. Because the organism
in initial, uncomplicated UTIs in women: single dose administration, short-course (3-4
days) medication regimens, or 7 to 10 day therapeutic courses. The trend is toward a
shortened course of antibiotic therapy for uncomplicated UTIs because about 80% of
cases are cured after 3 days of treatment.
Commonly used medications include Trimethoprim-sulfamethoxazole (TMP-
SMZ, Bactrim, Septra) and nitrofurantoin (Macrodantin). Occasionally, medications such
as ampicillin or amoxicillin are used, but E. coli has developed resistance to those agents.
Trimethoprim-sulfamethoxazole is considered the medication of choice because it is most
effective at reducing the number of fecal, vaginal, and periurethral bacteria.
Nitrofurantoin should not be used in patients with renal insufficiency because it is
ineffective at glomerular filtration rates (GFRs) of less than 50mL/min and may cause
peripheral neuropathy. Pyridium, a urinary analgesic, maybe prescribed to relieve the
discomfort associated with the infection.
Regardless of the regimen prescribed, the patient is instructed to take all the doses
prescribed, even if relief of symptoms occurs promptly. Longer medication courses are
indicated for men, and women with pyelonephritis and with other types of complicated
UTIs. In pregnant women, amoxicillin, ampicillin, or an oral cephalosporin is used for 7
to 10 days.

Long-Term Pharmacologic Therapy

Although brief pharmacologic treatment of UTIs for 3 days is unusually adequate

in women, infection recurs in about 20% of women treated for uncomplicated UTIs.
Infections that recur within 2 weeks of therapy do so because organisms of the original

17
offending strain remain in the vagina. Relapses suggest that the source of bacteriuria may
be the upper urinary tract or that initial treatment was inadequate or administered for too
short a time. Recurrent infections in men are usually due to persistence of the same
organism;’ further evaluation and treatment are indicated.
Reinforcement with new bacteria is the reason for more than 90% recurrent UTIs
in women. If the diagnostic evaluation reveals no structural abnormalities in the urinary
tract, the woman with recurrent UTIs may be instructed to begin treatment on her own
whenever symptoms occur 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. The patient may be taught to use dip-slide culture devices to detect bacteria.
If infection recurs after completing antimicrobial therapy, another short course (3
– 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an
antimicrobial agent may be prescribed. If there is no recurrence, medication is taken
every other night for 6 to 7 months. Long-term use of antimicrobial agents decreases the
risk of reinfection and may be indicated in patients with recurrent infections.
If recurrence is caused by persistent bacteria from proceeding infections, the
cause (ie, kidney stone, abscess), if known, must be treated. After treatment and
sterilization of the urine, low-dose preventive therapy ( trimethoprim with or without
sulfamethoxazole) each night at bedtime is often prescribed .

18
19
Name of Patient: Lerma Grace Canios Age: 8 years old Room No: 307
Diagnosis/Impression: Urinary Tract Infection Attending Physician: Dr. Macapasir

PRIORITY PROBLEM: 1

Nursing
Cues Objectives Intervention Rationale Evaluation
Diagnosis

SUBJECTIVE SHORT TERM: INDEPENDENT: The short term

goal was met for
Mother of the Hyperthermia After 30 minutes of 1. Cool with Tepid 1. This after 30 mins of
patient related to nursing interventions Sponge Bath decreases medical and
reports that infection the patient will be able temperature nursing
the patient manifest a decrease in through management
has been body temperature from 2. Provide adequate conduction the clients
experiencing 38.5 C to 37.5 C. amounts of fluid 2. Fluid loss can temperature
fever for contribute to lowered down
almost 3 days LONG TERM: fever and fluid from 38.5 to
can cool down 37.5
OBJECTIVE After 8 hours of core body
CUES: nursing interventions, 3. Provide additional temperature. The long term
Patient’s the patient will be able cooling 3. This helps goal was met
temperature- to maintain a normal mechanisms such decrease the patient did
is 38.5 C body temperature of as cold packs. temperature not experience
36.5-37.5 C and through re occurrence of

20
Increased absence of recurrent 4. Explain to conduction. fever and
WBC of 12 fever. Significant other 4. To increase maintained the
thousand about temperature the awareness of normal body
measurements the SO and temperature
Flushed skin and all available encourage from 36.5 to
treatments (e.g. involvement of 37.5.
Skin warm to tepid sponge bath) the SO in the
touch plan of care

5. Discuss with the

SO the 5. To prevent the
precipitating recurrence of
factors and fever
preventive
measures
6. Monitor client’s
temperature 6. To note
DEPENDENT: changes and
7. Administer development
antipyretics as
prescribe 7. Antipyretics
reduce the body
8. Administer temperature.
prescribed
antibiotics 8. This is to treat
the underlying
cause of fever

21
 (infection)

PRIORITY PROBLEM: 2

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE SHORT TERM: INDEPENDENT:
CUES: The short term
-The patient After 1 hour of 1. Encourage 1. Increased goal was
has reports of Acute pain nursing interventions, increase fluid intake hydration flushes partially met
pain of 6 in a related to the patient will be able: bacteria and toxins since the patint
pain scale
irritation and -verbalize 2. Investigate report 2. Urinary retention was able to:
with 10 as the
highest and 0 inflammation understanding of the of bladder fullness. may develop, -verbalize
as the lowest. of bladder disease condition causing tissue understanding of
-Pain in the and urethral - to express feeling of distention (bladder or the disease
hypogastrium mucosa improved comfort. kidney), and condition
area - identify measures potentiates risk for - express feeling
-Burning effectively in relieving further infection. of improved
sensation
pain 3. Observe for 3. Accumulation of comfort.
when voiding
-Frequency of - demonstrate use of changes in mental uremic waste and - identify
pain is over 8- relaxation skills and status, behavior or electrolyte measures
10 times/day diversional activities as level of imbalances may be effectively in
indicated consciousness. toxic to the CNS. relieving pain
OBJECTIVE -a decrease of pain - demonstrate
CUES: scale from 6 to 3. 4. Encourage use of 4. To divert the use of relaxation
LONG TERM: diversional activities client’s attention, skills and

22
The patient (TV/radio, playing, thus relieving pain diversional
grimaces and After 1 week of socialization with activities as
sighs. nursing interventions, others). Suggest use indicated
the patient will be able of relaxation But the patient
to manifest absence of technique and deep was not able to
pain. breathing exercises. reach the pain
scale of 3 out of
5. Provide comfort 5. Promotes 10 instead
measure like warm relaxation, refocuses reported a pain
compress, attention, and may scale of 4-5 out
enhance coping of 10.
abilities.

6. Help patient 6. Making the client For the long

assume position of comfortable lessens term goal
comfort. pain continue plans
of care
DEPENDENT:

7. Administer 7. Analgesics
analgesics as depress central
ordered and nervous system,
document thereby reducing
effectiveness and pain.
adverse effects.

8. Administer 8. To eradicate

23
 antibiotics as ordered causative agent

COLLABORATIVE:
9. Refer client to 9. To provide client
nutritionist proper nutrition for
tissue healing .
10. Refer client to 10. For further
medical technologists evaluation

PRIORITY PROBLEM: 3

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE SHORT TERM: INDEPENDENT:
CUES: The short term
After 1 hour of 1. Monitor patient’s 1. Accurate intake goal was met
Mother Altered nursing interventions, voiding pattern: and output since the client
reports that urinary the patient will be able document and report measurements are was able to:
the patient pattern to: intake and output. essential for correct -verbalize
has a change related to -verbalize fluid replacement understanding of
of voiding irritation and understanding of the therapy the condition
pattern from inflammation condition -voice increased
the usual 6- of the bladder -voice increased 2. Let the patient 2. Urinary stasis in comfort
7/day to 8- comfort empty the bladder the bladder -express
10/day. -express feelings about every 2 to 3 hours enhances feelings about

24
 condition proliferation of condition
microorganisms
Patient LONG TERM: For the long
reports of After 5 days of 3. Encourage fluid 3. To moisten term goal
continue plans
burning nursing interventions, intake up to 3000ml mucous membranes
of care
sensation the patient will be able every 24 hours. and dilute chemical
when voiding to manifest normal materials within body
urinary elimination. 4. Provide 4. To keep the urine
information about acidic and to reduce
OBJECTIVE dietary changes bladder irritation
CUES: (increase Vitamin C
intake from fruits).
Patient
voided 5 5. Alert patient and 5. Adequate
times in a family members to education increases
scanty signs and symptoms patient’s and family
amount in an of full bladder: member’s ability to
8-hour shift. restlessness, maintain health level
abdominal and to prevent
The patient discomfort, sweating, patient from harming
grimaces and chills. self.
sighs.
6. Instruct the patient 6. To prevent the
in health promotion reoccurrence of UTI
strategies:
-increase fluid intake
of at least 3L/day

25
-Advise client to
avoid caffeinated
beverages or any
beverages that may
irritate the bladder
-correct hygienic
practices

DEPENDENT:

7. Administer 7. This will prevent

antimicrobial drugs ifcolonization of the
bacteria continue to periurethral area and
appear in the urine. recurrence of
infection
8. Administer 8. Help alleviate
Antispasmodic as bladder irritation.
prescribed

26
PRIORITY PROBLEM: 4

NURSING
CUES OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE SHORT TERM: INDEPENDENT:
CUES: Fluid volume
deficit due to After 8 hours 1) Weigh patient -establish a The short term
Mother reports excessive losses of nursing and compare baseline data goal was partially
that the patient through normal interventions, the with recent met since the
has several routes patient will be able weight history patient was able
episodes of to demonstrate to demonstrate
vomiting. adequate fluid 2) Monitor IV flow -to ensure stable vital signs,
balance as rate closely; accurate status of moist mucous
Mother reports evidenced by stable record IV and fluid intake membrane, good
that the patient vital signs, moist oral fluid intake. skin turgor,
has a change of mucous membrane, capillary refill, but
voiding pattern good skin turgor, 3) Closely monitor -to verify failed to have an
from the usual 6- capillary refill, and record possibilities of individually
7/day to 8- individually output. imbalances appropriate
10/day. appropriate output. output.
4) Note changes in -v/s are the basic
The mother LONGTERM: v/s indicators of life
reported that the After 3 days of For the long term

27
patient vomited 3 nursing goal continue
times prior to interventions, the 5) Discuss with SO -this helps child plans of care
admission and patient will maintain importance of be comfortable
vomited 7 times homeostasis in oral intake. and makes him
last 1/10/10 terms of fluid Suggest SO to cooperate
OBJECTIVE balance. put straw when
CUES: kid is to drink or
offer fluids in
Patient has dry between meals
mucous
membranes 6) Inform the SO -to solicit
the importance cooperation not
Dry and cracked of monitoring only from the
lips the intake and patient but also
output of the with the SO
Patient voided 5 patient.
times in a scanty
amount in an 8- 7) Encourage -to replenish fluid
hour shift. patient to loss
increase fluid
intake.

DEPENDENT:
8. Administer - To correct fluid
Intravenous fluid imbalance
as prescribed by

28
 primary health
care provider.

PRIORITY PROBLEM: 5

NURSING
CUES OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE SHORT TERM: INDEPENDENT: The short term goal

CUES: Disturbed sleep Short-term: 1. Provide calm,  To promote was met
The patient pattern related At the end of 8 hours quiet sleepiness and The Patient’s SOs
reported to discomfort nursing intervention environment avoid were able to:
decreased secondary to • The patient’s and manage destruction of a) Report
S.O. will be controllable sleep.
amount of UTI improvement
able to: sleep-disrupting
sleep 5-7 hrs. in sleep/rest
a) Report factors.
pattern of the
from 8-10 hrs improvement in 2. Recommend  Soothing music child
and have a sleep/rest quiet activities facilitate b) Verbalize
feeling of pattern of the such as listening sleepiness understandin
awakening child to soothing
g of the sleep
b) Verbalize music
during night disorder
3. Put the child in

29
due to the urge understanding the best  Comfortable c) Identify
to urinate of the sleep comfortable position individually
disorder position. promotes sleep appropriate
c) Identify and rest. interventions
OBJECTIVE
individually 4. Determine to promote
CUES appropriate client’s usual child’s sleep
 Provides
> appears interventions to sleep pattern comparative
restless promote child’s baseline The patient was able
>the patient sleep 5. Instruct patient to appear calmed
looks sleepy. to perform  To decrease and rested.
relaxation tension, prepare
• The patient will techniques. for rest/sleep. For the long term
be able to: goal continue plans
a) Appear calmed DEPENDENT: of care
and rested
6. Administer
medications as
LONGTERM: prescribed  Pain medication
After 3 days of nursing and anti
intervention, spasmodic can
• The patient will give client
be able to: comfort thus
a) Report enhances sleep
normality in COLLABORATIVE and rest quality.
sleep/rest 7. Refer to sleep
pattern within specialist/  To further
the range of 8- laboratory when assess clients
10 hours. problem is condition and
b) Report absence unresponsive to promote proper
of alteration to medications sleep pattern

30
 sleep pattern.
c) Maintain
normal and
adequate time
for sleep and
rest.

31
Discharge Planning

The discharge plan includes home medications ordered by the physician,

health teachings, out-patient follow-up and diet of patient. It is designed to continue
nursing management as we, student nurses, assist the patient to regain her pre-admission
health status. It is also aimed on encouraging active participation of the patient’s support
group to aid her in achieving the goals of the plan of care and will serve as a guide for the
patient on what to do after she is discharged.
The home care nurse, if available, will reinforce and clarify information
about dietary changes and fluid restrictions, the need to monitor sign and symptoms,
daily body weights, and the importance of obtaining follow-up health care. Assistance
may be given in scheduling and keeping appointments as well. The patient is encouraged
to gradually increase self-care and responsibility for accomplishing the therapeutic
regimen.

Medication:
• Encourage strict medication compliance.
• Explain to the client and family members the mechanism of action and indication
of the prescribed medication.
• Inform the client and family members of the side and adverse effects of the
medication and its preventive measures. Instruct them to consult a member of the
health care team if any of the reactions occur to the patient.
• It is very important that the significant others knows how to administer the
medications with regard to the timing and the dosage of the medications
• Make sure that the client takes all the medication as prescribed to prevent
resistance and further complications.
• Patients should take antibiotics for a week or two to ensure that the infection has
been cured.

Exercise:
• Before letting any exercises make sure that the exercises are approved by the
physician.
• Conserve energies by balancing activity with rest periods.

Health Teachings:
• Explain to the patient and significant others to abide with the prescribed
medications.
• Instruct the significant others for compliance to medication, diet, exercises and
activity to prevent further complications.
• Teach her to wipe from front to back after she uses the bathroom
so that germs from the rectum aren't wiped into the vagina.
Diet:
• Consume sufficient calories

32
 • It's also important that the child drink enough fluids every day so
the urine isn't concentrated and to help flush out bacteria.
Encourage the child to drink plenty of fluids.
• Cranberry juice, especially, has been shown to help prevent
urinary tract infections. There is evidence that cranberries
reduce the risk of the bacteria's adhesion to bladder cells.
• Avoid coffee, alcohol, and soft drinks containing citrus juices and
caffeine until the infection has cleared. These can irritate the
bladder and tend to aggravate the frequent or urgent need to
urinate

Out-patient follow-up:
• Ask the significant others for a follow up check up of the patient, with her
physician by health assessment.
• Instruct the significant others to report any unusualities observed with regards to
the medications and any untoward side effects as she is taking the said
medications.
• During follow up care, assess the patient regarding compliance to discharge
instruction and the present health condition.

Spirituality:
• Encourage the significant others or any religious group to pray over the patient.
• Encourage the family of the patient to give spiritual support to the patient.

33
Bibliography

Black, Joyce and Hawks, Jane Hokanson. Medical Surgical Nursing: Clinical
Management for
Positive Outcomes. 7th Ed pp. 1839 - 1843. Singapore: Elsevier Inc, 2005.

Bauman, Robert. Microbiology with Diseases by Body Systems. 2nd Ed pp. 667-672.
Singapore: Pearson
Education South Asia PTE. LTD., 2008.

Paradiso, Catherine. Pathophysiology. 2nd ED vol. 1 page 20. Lippincott William &
Wilkins, 1999.

Smeltzer, Suzanne et al. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.

11th ed
Vol. 1 pp. 628 643. Lippincott Williams & Wilkins, 2008.

Marieb, Elaine. Essentials of Human Anatomy & Physiology. 6th Ed pp. 385 – 403.
Singapore: Pearson
Education Asia PTE LTD, 2002.

Chiras, Daniel. Human Biology: Health, Homeostasis, and the Environment. 4th Ed pp
201 – 209.
Canada: Jones and Bartlett Publishers, 2002.

34
 In Partial Fulfillment of NCM 102

A Case Study of an 8 year old Pediatric Patient Diagnose with

Urinary Tract Infection is

Presented To:

Mr. Ed Micheal A. Carbonel, RN

Submitted By:

Calalang, Janssen D.

Closas, Robert Jones H.

Cui, Marc Anthony L.

De la Cruz, Emerson Jade T.

Cagas , Christine V.

Chua, Grace Gift T.

Dagpin, Ailyn Hope S.

Diola, Nissa Kristine D.

Ditona, Dianne S.

Dumalogdog, Ma. Noemi P.

Fajardo, Beatriz Jovita D.

January 22, 2009

35
 Table of Contents

Introduction…………………………………………………………………..1-2

Scope and Limitations……………………………………………………...2-3

Assessment…………………………………………………………………..3-5

Diagnostic and laboratory test……………………………………………6

Anatomy and Physiology…………………………………………………..7-14

Narrative Pathophysiology…………………………………………………14-15

Schematic Pathophysiology (concept map) ……………………………16

Medical management………………………………………………………..17-18

Nursing Care Plan……………………………………………………………19-29

Discharge Plan ………………………………………………………………30-31

Bibliography…………………………………………………………………..32

36
37
38