Case Study 1

A Case Study of a Patient with a Diagnosis of Cystitis

Abungin, Jemel Joy Aguilar, Roxette Aranda, Mel Gillian Atangan,Ian Keith Banda, Erika Shayne Bantucan, John Michael

2012

INTRODUCTION Mr. EDP is a 51 y/o male that was diagnosed to have cystitis and has chief complaint of abdominal pain at right upper quadrant for 3 to 4 days prior to confinement. Cystitis refers to inflammation of the lining of the bladder. It usually occurs when the normally sterile urethra and bladder (lower urinary tract) are infected by bacteria and become irritated and inflamed. Cystitis is fairly common and can affect both men and women and people of all ages. However, it is more common in women. Cystitis is the most common form of urinary tract infection and occurs mainly in women. But men and children also can experience cystitis. Elderly men and women are especially at high risk for cystitis. Nearly one-third experiences the condition. Bacterial infection causes most bouts of cystitis. Although the urinary tract is normally sterile, germs sometimes may enter the body through the urethra and grow inside the bladder. This bacterial growth causes the inside walls of the bladder to become inflamed. That inflammation leads to the common symptoms of cystitis. Infection from intestinal bacteria is by far the most frequent cause of cystitis, especially among women, who have a very short urethra (the tube through which the urine passes from the bladder to the outside). Normally, urine is sterile (there are no micro-organisms such as bacteria present). Between 20 to 40 per cent of women will get cystitis in their lifetime. However, it is possible to have bacteria in the bladder without having any symptoms (especially in the elderly). There can be several reasons for the bacteria settling in the bladder. Inadequate emptying resulting in stagnation of urine may lead to infection. This may be caused by some drugs (for example, antidepressants), immobility, abnormal bladder control and constipation. Even the small drop which is always left behind may contain bacteria.

PATHOPHYSIOLOGY The cascade of events leading to the development of cystitis begins with an insult to the bladder or urothelium,which is the layer of transitional epithelium in the wall of the bladder,uereter,and renal pelvis, external to the lamina propria,which often occurs after a bout of bacterial

cystitis,childbirth,pelvic surgery,or use of urologic instrumentation. Whereas the injured urothelium in normal individuals heals after appropriate therapy, this is not the case in patients with cystitis. As suggested in recent studies,these patients have increased levels of epithelial growth factor in their urine that prevent normal epithelial healing. Abnormalities develop in the glycosaminoglycan lalyer, the defensive mucosal lining of the bladder epithelium, allowing irritating urinary

metabolites such as potassium to leak into the submucosal space and cause depolarization of smooth muscle in the bladder and pelvis, as well as activation of sensory nerves. Leakage also causes an inflammatory reaction characterized by the proliferation and activation of mast cells and the subsequent release of histamine and other mediators that stimulate sensory nerve fibers and produce local tissue damage. The interaction between mast cells and activation of capsaicin-sensitive nerve fibers , that are involved in pain transmission results in the release of substance P, a mediator of inflammation, and other neuropeptides, producing additional cell damage and further mast cell activation . As the effects of these actions continue, they produce further injury to local tissue- the GAG layer and bladder smooth muscle and eventually lead to fibrotic changes in the bladder. If this sequence of events is left untreated, the bladder will eventually decrease in size and its functional capacity will be severely compromised. In addition, repeated inflammation and activation of C0fibers can trigger neural up-

regulation and neural changes in the spinal cord, causing chronic pelvic pain, urgency and frequency.

HISTORY Mr. E.D.P, is a 51 year old male patient in the emergency room that was diagnosed to have cystitis has a chief complaint of persistent abdominal pain a few hours prior to confinement. . He experienced having right upper quadrant abdominal pain for 3 days, no vomits, no fever. Before going to the emergency room the patient took some medications like AlMg(OH)3 and other unrecalled medicines to relieve pain but the pain has no relief. He had undergone WAB UTZ which shows Gallbladder Polyp, Diffuse fatty liver, Cystitis and UTI. Urinalysis shows pus cells of 8-9 UPF and all other test are normal. After

reading the WAB UTZ result the doctor decided to be confined the patient in the hospital for several test .

NURSING PHYSICAL ASSESSMENT Patient x is male who looks healthy. His vital signs was noted as Temperature 36c , Blood pressure 200/120 mmhg, Heart rate by radial pulse palpation 65 beats per minute, and respiration Rate 22 cycle per minute. His head is norm cephalic. He has a normal texture of hair, his scalp is without lesions and tenderness, His external ear is without lesions, masses, and tenderness. His Auditory Canal is normal. His nose is normal without negative discharge. His Tongue is without lesions, and his Gums and Mucosa are negative in swelling, bleeding, and infection. His Pharynx and Tonsillar Fossa are normal. In his abdomen, positive tenderness on deep palpation in the right flank abdomen. He has normal flexion, extension, lateral rotation and tilting of his neck. His Thyroid is non-palpable and normal in size & consistency, and

has negative lesions. He has normal resonant percussion and has normal vesicular breath sounds. His nails are without cyanosis, clubbing and his palms are normal in texture. His skin is yellowish in color and the patient has jaundice. He has Wrinkles in his Forehead, Close Eyes, shows Teeth normally, he can hear clearly, and coughs normally. He Shrug his shoulders normally. He protrudes his tongue normally. He has normal Sensory, Sharp, Vibration and Position Sense.

RELATED TREATMENTS The patient was prescribed to take antiulcer agents medication such as Ranitidine it is used for healing and prevention of ulcers. In addition, decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid. They suppress the normal secretion of acid by parietal cells and the mealstimulated secretion of acid. They accomplish this by two mechanisms: Histamine released by ECL cells in the stomach is blocked from binding on parietal cell H2 receptors, which stimulate acid secretion; therefore, other substances that promote acid secretion (such as gastrin and acetylcholine) have a reduced effect on parietal cells when the H2 receptors are blocked. On the other hand, the patient also taking Aluminum Magnisium Hydroxide to reduce the acidity of your urine and the burning sensation when you urinate The patient also taking Metropolol to reduces the force of contraction of heart muscle and thereby lowers blood pressure. By reducing the heart rate and the force of muscle contraction, metoprolol reduces the need for oxygen by heart muscle. Since heart pain (angina pectoris) occurs when oxygen demand of the heart muscle exceeds the supply of oxygen, metoprolol, by reducing the demand for oxygen, is helpful in treating heart pain. According to ninemsn Urinate often if you can - don't hold on to a full bladder. Try to relax and refrain from anything that might cause stress or anxiety. Avoid sexual intercourse until the symptoms have passed. Wear loose fitting garments,

preferably made of a soft, natural fiber like cotton. Apply warm packs or hot water bottles to your lower back and stomach for some relief of pain.

NURSING CARE PLAN Mr. EDP has experiencing abdominal pain at right upper quadrant for 3 to 4 days PTC has a pain scale of 8 out of 10 related Cystitis is a term that refers to urinary bladder inflammation that results from any one of a number of distinct syndromes. It is most commonly caused by a bacterial infection in which case it is referred to as a urinary tract infection. Interstitial cystitis (IC) is considered more of an injury to the bladder resulting in constant irritation and rarely involves the presence of infection. IC patients are often

misdiagnosed with UTI/cystitis for years before they are told that their urine cultures are negative. The cause of IC is unknown, though some suspect it may be autoimmune where the immune system attacks the bladder. He has a nursing diagnosis of acute pain related to urinary bladder inflammation as manifested by facial grimace, restlessness, irritability, inability to concentrate, limited range of motion and pain scale: 8 out of 10. The desired outcome After 8 hours of nursing interventions, the patient will verbalizes minimized or controlled feeling of pain, follow prescribed therapeutic regimen; and

demonstrate use of methods that provide relief.. The nursing interventions are assessing pain, noting location, characteristics, intensity (0-10 scale) because it helps evaluate degree of discomfort and may reveal developing complications. The nurse also notes urine flow and characteristics because decreased flow may reflect urinary retention with increased pressure in upper urinary tract. Then, encourage patient to verbalize concerns. active listen these concerns and provide support by acceptance, remaining with patient and giving appropriate information to reduce anxiety or fear that can promote relaxation and comfort. In Addition, Provide comfort measure like back rub or deep breathing exercises in order to reduce muscle tension, promotes relaxation, and may enhance

coping abilities. Moreover, assist with range of motion exercises and encourage ambulation because it reduces muscle or joint stiffness and ambulation returns organs to normal position and promotes feeling of well being. And the nurse also investigate and report abdominal muscle rigidity, involuntary guarding and rebound tenderness so that the requiring prompt medical intervention. After 8 hours of nursing interventions, the patient was able to report pain is reduced or controlled to a tolerable extended, follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

RECOMMENDATIONS Patient's fluid intake should be increase. Going often to the bathroom helps wash bacteria out of the infected bladder. To keep the bladder full, patient should drink plenty of water or other kinds of fluid. He should avoid alcohol and coffee, which can irritate the bladder. Mr. EDP should be advice to drink 10 ounces of fluid every half-hour until the burning goes away. He should also drink cranberry or blueberry juice because studies show that drinking these juices helps rid the bladder of infection more quickly. Both juices also help prevent attacks of cystitis. He should be instructed to increase vitamin C intake. Oranges, pineapples, tomatoes, and leafy green vegetables are good sources but if the acidity of the above juices and fruits can't be tolerated, add baking soda (one teaspoon) to 10 ounces of fluid. Drink this two or three times a day. After burning disappears, continue drinking 10 ounces of fluid every hour for two to three more days. If pain is severe and continues after trying these steps, painkillers should be used by the patient because it may help relieve symptoms. One kind, called phenazopyridine, is often used specifically to relieve painful urination. It requires a prescription. Patient should urinate frequently. Bacteria can be wash out of his bladder by going to the bathroom every hour or Relax and let his bladder empty completely.