Case Study UTI PDF

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Case Study/Nursing Process Mrs. Johnson, a fashionably dressed and groomed woman, 60 years of age, arrived at her primary care physician office for her scheduled annual appointment. Mrs. Johnson has had an annual examination for the past 10 years. She is married and has three adult children. She does not drink alcohol or smoke. She exercises three times per week at the local health club. She has just retired from working at the local police department as an administrative assistant for 40 years. She is active in her local church group and with the civic woman’s club. Mrs. Johnson reported that the past 2 weeks she has had to “go to the bathroom a lot and it burns when I pass my water” and that her “urine smells strong and is dark in color”. When asked how much fluid she consumes daily, she responded, “I drink one big cup of coffee in the morning, one can of diet soda at lunch, one glass of milk at dinner, and may be one glass of water at the bedtime.” She also stated that “My skin feels very dry and my lower back hurts.” Vital signs revealed a temperature of 100 F, pulse 100bpm, lying BP of 140/78mmhg, and a standing BP of 110/70. Height is 5 feet 4 inches; weight, 135 pounds. Urine specimens for urinalysis and culture and sensitivity were ordered by the physician. The nurse observed that the Mrs. Johnson, urine has foul smelling, dark amber color, cloudy, and thick. Her skin turgor revealed tenting with the shape remaining for 15 seconds. Her fluid intake for the past 24 hours was 950 ml. The urinalysis revealed specific gravity >1.030, and the culture and sensitivity report disclosed the presence of Escherichia coli with sensitivity to all penicillin. Her hemoglobin was 14gm/dl, Hematocrit was 45% and WBC count was 15,000. In addition Mrs. Johnson guards her lower back upon movement. On the basis of all the data the physician diagnosed her Urinary tract infection.

1. What is Urinary tract Infection? Write the definition, pathophysiology and sign and symptoms? ● Definition - A urinary tract infection (UTI) is a common infection that can affect any part of the urinary system, including the kidneys, bladder, and urethra. ● Pathophysiology - The urinary tract, from the kidneys to the urethral meatus, is normally sterile and resistant to bacterial colonization despite frequent contamination of the distal urethra with colonic bacteria. The major defense against urinary tract infection (UTI) is complete emptying of the bladder during urination. Other mechanisms that maintain the tract’s sterility include urine acidity, the vesicoureteral valve, and various immunologic and mucosal barriers.

● Signs and symptoms - Urinary tract infections (UTI) do not always show any symptoms, but when they do some symptoms are: a) A strong, persistent urge to urinate b) A burning sensation when urinating c) Passing frequent, small amounts of urine d) Urine that appears cloudy e) Urine that appears red, bright pink or brown, which is a sign of blood in the urine f) Strong-smelling urine g) Pelvic pain 2. What type of assessment would you like to plan for Mrs. Johnson and why? How would you carry on that assessment, what specific questions would you ask? The assessment I would use would be a focused assessment to address her chief complaint which was pain upon urination. I would begin by taking down her past medical, social, and family HX. I would ask the following questions: How long have you been in pain? How would you describe your pain? Does the pain go anywhere else or does it only occur when you urinate? 3. Please write the subjective and objective data for Mrs. Johnson. ● Subjective data: a) Mrs. Johnson says that “I go to the bathroom a lot and it burns when I pass my water.” b) She also states, “my urine smells strong and is dark in color.” c) Mrs. Johnson also says that, “My skin feels very dry and my lower back hurts” ● Objective data: a) Vital signs revealed a temperature of 100F, pulse 100bpm, lying BP of 140/78mmhg, and a standing BP of 110/70. b) The nurse observed that Mrs. Johnson, urine has foul smelling, dark amber color, cloudy, and thick c) The nurse observes that Mrs. Johnson skin turgor revealed tenting with the

shape remaining for 15 seconds d) Mrs, Johnson’s urinalysis revealed specific gravity >1.030, and the culture and sensitivity report disclosed the presence of Escherichia coli with sensitivity to all penicillin e) Mrs. Johnson’s hemoglobin was 14gm/dl, Hematocrit was 45% and WBC count was 15,000 f) The nurse observed that Mrs. Johnson guards her lower back upon movement. 4. Based on your data, write 2 nursing diagnoses with their definition or characteristics. a) Nursing diagnosis 1: Acute Pain related to infection of the bladder as evidence by spasm in the lower back b) Nursing diagnosis 2: Deficient fluid volume related to inadequate fluid intake as evidence by decreased skin turgor 5. What would be expected outcome for your nursing diagnosis? a) Nursing diagnosis 1 outcome: “Client will report satisfactory pain control at a level less than 3 on a scale of 0 to 10” b) Nursing diagnosis 2 outcome: “Patient demonstrates lifestyle changes to avoid progression of dehydration” 6. Plan your interventions with their rationale. a) Nursing diagnosis 1 intervention/rationale: 1. “Assess client’s description of pain such as quality, nature and severity of pain.” Rationale: Assessment of pain experience is the first step in planning pain management strategies. 2. “Encouraged the use of analgesic (e.g., acetaminophen) or antispasmodics (e.g., phenazopyridine).” Rationale: Antispasmodic and analgesic agents are useful in relieving bladder irritability, spasm, and pain. 3. “Instruct to avoid coffee, tea, alcohol, and sodas.” Rationale: These food items cause irritation to the urinary system and should be avoided. 4. “Apply a heating pad to the suprapubic area or lower back.” Rationale:

This measure alleviates the pain. b) Nursing diagnosis 2 intervention/rationale: 1. “Monitor BP for orthostatic changes. Monitor HR for orthostatic changes.” Rationale: Monitor HR for orthostatic changes. 2. “Assess color and amount of urine.” Rationale: Concentrated urine denotes fluid deficit. 3. “Monitor serum electrolytes and urine osmolality, and report abnormal values.” Rationale: Elevated blood urea nitrogen suggests fluid deficit. Urine specific gravity is likewise increased. 7. What health teaching would you like to give it to Mrs. Johnson? “ You should keep your genital area clean and wear clean, dry cotton underwear. You should wipe from front to back after urinating or a bowel movement. You should drink plenty of fluids. Drinking cranberry juice may be helpful.” 8. Please change the following closed-ended questions to the open-ended questions. a. Are you able to take care of yourself at home? “How are some of your ways of caring for yourself at home when you are not feeling well?” b. Is your pain in the back? “Are you feeling any pain in your back from a scale of 0-10, 0 being no pain and 10 being the worst pain you’ve ever felt? Can you describe your pain for me?” c. Are you satisfied with your health status? “How satisfied are you with the status of your health?” d. Does your urine always look like this color? “Can you describe to me the color your urine is usually?”...