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m    

 
INTRODUCTION
p is a bacterial infection that affects any part of
the urinary tract.
p symptoms include frequent feeling and/or need to
urinate, pain during urination, cloudy urine.
p the main causal agent is Escherichia coli.

p are a common, potentially serious, and (especially


in young children) often occult bacterial infection
of childhood.
p during childhood, UTI occurs in approximately 3-
5% of girls and 1% of boys.
OBJECTIVES
This study aims to gather significant data to
broaden our knowledge with regards to the
condition of the patient and to improve our
abilities as future health care providers.
Moreover, this study will enable us to:

p To apply the acquired skills we obtained from


our classroom set-up.
p The group aims to perform physical
assessment, gather data and perform history
taking to solidify the present diagnosis of the
client; to further understand the disease
process involved in this case.
p To gather insights on the pharmacologic and
other therapeutic management required in this
condition.
p It also aims to identify the development and
changes in the condition of the patient.
p To identify nursing problem that will be the
basis of the care plan.
p To develop the plan of care and implement
nursing intervention relevant and suitable to
our client.
BIOGRAPHICAL DATA
Name: Star
Age: 5 years old
Gender: Female
Date of Birth: June 28, 1995
Address: Upper Bicutan, Taguig
City
Date of Admission: May 3, 2011
Hospital: Taguig-Pateros Distric
Hospital
Percentage of reliability: 90%
Informant: Patient and her Father
CHIEF COMPLAINT
p Body weakness and lower back pain
HISTORY OF PRESENT
ILLNESS
p Two years prior to admission, patient star was
brought to Taguig ² Pateros District Hospital for
fever, headache, body weakness and pain when
urinating and was diagnosed with Urinary Tract
Infection.
p One year prior to admission, the Urinary Tract
Infection had recurred and she was then again
brought to TPDH ² ER.
p Three days prior to admission, the patient and
his family went to swim at Sea Breeze. Later that
night, patient star has been experiencing dry
cough and low grade fever.
p Two days prior to admission, Star reported pain
when urinating and cries frequently according to
her father. Fever and cough are still notable
according to her father with accompanying body
weakness and change in appetite. Her mother
gave her Bisolvon 5mL every after meal together
with Paracetamol 5mL.
p Eight hours prior to admission, high grade fever
and cough still persisted and Star reported to
have pain in her lower back. Star urinates
frequently and still reported pain when
urinating. Pain on her back is still present. Body
weakness is notable and they continued to give
her Paracetamol and Bisolvon.
p Thirty minutes prior to admission, the patient
still verbalizes pain. Fever and cough still
persisted. Star is said to be very weak and
vomited of about 350 mL of gastric content, thus
prompted her father to rush Star to TPDH
Emergency Room.
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p Star has been hospitalized for the first
time when she was 3 years old in Taguig ²
Pateros District Hospital. She was then
diagnosed with Urinary Tract Infection. She
was brought to the same hospital when she
was 4 years old and was diagnosed with the
same problem.
p Other than that, she also experienced
seasonal cough and fever that can be relieved
with paracetamol and Bromhexine.
p Star has no known allergy to foods or
medications and has completed the extended
program of immunization (EPI).
ã
 
 
 
p Star is a playful child according to her
father. She often holds her urge to urinate
until she·s done playing. She lives with her
parents and two siblings. Her mother is a plain
housewife and her father works as a carpenter
on contractual basis. She is fond of eating junk
foods and candies and drinking soft drinks. She
has no known allergies and sleeps 8 ² 10 hours
a day. Their family is a Roman Catholic but
they seldom goes to church.
GORDONS
FUNCTIONAL HEALTH
PATTERN
ã     ã  
 
  
p Star sees herself as a typical child who is
dependent to her parents especially to her
mother.
        ã 
p Star is fond of eating junk food and sweet
candies. Her favorite foods are fried chicken
and spaghetti especially from a known fast food
chain. She consumes less than eight glasses of
water per day and she also drinks 1 to 2
glasses per day.
ã      
p Her father said that Star is used to hold
her urge to urinate when she·s busy playing
with her friends. She experienced frequency
when urinating accompanied with pain.
ã      
 
p Before hospitalization, her activity
includes playing and watching over her little
sibling.
p During hospitalization, her activities is
now limited to sitting on her chair and going to
the comfort room.
     ã  ã 
p Star has no problem with her senses.
When she experience any discomfort, she
reports it immediately to her parents. Star
have just graduated from her Preparatory
School. She·s expecting to enter Grade School
this June.
ã  
 

p Before hospitalization, Star·s sleep pattern
was 8-10 hours. She get up from bed during
summer at 7 to 8 am and goes to bed at 9 to 10
pm. She easily falls asleep since she·s always
tired playing, according to his father.
p During hospitalization, she couldn·t sleep
well since she couldn·t lie in a bed due to
unavailability so she·s just sitting in a chair.
According to her father, Star is able to sleep
whenever he carry her.
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p Star said that she is a good child of her
parents; she worries about her little sibling
that she often plays with since she·s away.
She·s not scared or anxious about being
hospitalized or getting pricked with different
sizes of needles. Like what her father said that
she·s used to that since she have been admitted
their twice.
      ã 
p Star said that she loves her parents and
her two siblings. She·s the second child among
three children.

   

  ã 
p Star is just a 5 year old child
ã     

  
p Her father said that stressors often came
from her playmates and whenever she wants
something that they couldn·t provide. She copes
with this through crying.
REVIEW OF SYSTEMS

 
  
   
General: (+) headache
(+) low grade fever
(+) lower back pain
(+) suprapubic pain
Integumentary: (-) petechiae
(-) pruritus
Respiratory: (-) tachypnea
Cardiovascular: (-) chest pain
(-) palpitation
_       

  
    
   
  
 
Renal: (+) burning
sensation or pain
on urination
Genital: (-) pain
Musculoskeletal: (-) tremors
(+) body weakness
  
 
 
      
Hematologic: (-) bleeding
Endocrine: (-) for any significant
findings
PHYSICAL EXAMINATION

     
   
General Appearance: -The client seemed weak,
but able to respond to
questions. There were no
appearance of muscle
atrophy.
-1L PNSS x 83-84 gtts/ min
to run for 12hrs hooked at
right hand.

Vital Signs: PR: 135


RR: 52
Temp: 38.7
Skin:    

  
   


     

      
       


   
  

  
Head: The client has evenly
distributed black hair. No
infestations found and no
palpated lesions.
Eyes: No periorbital edema and
tearing on the lacrimal
duct noted. Pupils are
equally round reactive to
light and accommodation.
    
   
  
   
     
      
    ã   
   


Nose: No epistaxis, nasal flaring and


congestion; nasal septum is in
the midline

Throat (Mouth, Teeth and There was noticeable drying of


Pharynx): lips. Teeth have presence of
tooth decay. The rest of the oral
cavity has no lesions or any
deviations. Tonsils are not
inflamed.
Neck There are palpable lymph
nodes upon palpation of the
neck.
   
 
 
 
     
   
   
       
  
 

   
  

Abdomen: No distention was noted.
Client has normal bowel
sound during auscultation.
No rigility when palpated
Lower Extremities: No visible and palpated
lesions or bruises on both
legs.
MEDICAL DIAGNOSIS

Urinary Tract
Infection
NURSING
DIAGNOSIS:
Pain related to infection
within the urinary tract, as
evidenced by pain scale of 7
out of 10.
DIFFERENTIAL
DIAGNOSIS
 m     
      
Definition is a bacterial is a bacterial
infection that infection that
affects any part affects any part
of the urinary of the urinary
tract. tract.
Causes -poor hygiene - autoimmune
-excessive intake -mast cells
of salty foods - toxic
-E. coli infection -Stress

 

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Risk Factors: -gender (female) -Middle aged
-Prlonged use of -Female
catheter
-sexual
intercourse
-DM
Diagnostic -Urinalysis -kcl test
Examination: -Urine Culture -urinalysis
-cystoscopy
-Flowmetry
ANATOMY AND
PHYSIOLOGY
LABORATORY AND DIAGNOSTIC
TEST
 
   
 
       

Color : Yellow Normal White 0-5 hpf Above


yellow Blood Normal
Cells: 5-
10 hpf
Transpa Hazy Normal Red 0-2 hpf Normal
rency: Blood
hazy Cells:
0-1 hpf
Reactio 5.0 ² 9.0 Normal Squamo 0-3 hpf Normal
n-PH : us Cells:
5.0 0 -1 hpf
COURSE IN THE
WARD
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·:30am (-) ANST
- Cefuroxime goven, 250mh
TIV
- performed TSB
- T: 38.1 ° C
    

    
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 ã 


        

  
   
 
10:00am -Physical Examination done,
ROS
-PNSS level of ·00 cc
- T: 38.· ° C Febrile
-continued TSB
12:00pm Cefuroxime, 250mg TIV
-T: 38.1°C, (+) headache
- performed TSB
ï  -afebrile T: 37.1° C
DISCHARGE PLAN
edication
p Encourage the patient to have a strict compliance
with regards to the medcation to attain therapeutic
effects.
p Remind the family members for the prescribed
medications by the physician and report immediately
of adverse reaction.
p Explain to the family members the action of the drugs
that the patient is taking
p Cefuroxime
p Paracetamol
p Vitamin C
xercise
p The patient must resume daily activities
reatment
p Advise patient to take medications as scheduled
and as prescribed for fast recovery
ealth teaching
p Instruct the family for proper personal hygiene to
avoid complication; frequent handwashing is
advised.
ut-Patient ² Advise client to visit or have a
follow-up check-up with her attending physician
for the recurrence of present condition.
iet ² instructed the client to have a low sodium
diet and increased fluid intake.