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I. INTRODUCTION
Is a congenital in which the urethral meatus is located on the urethral side or under surface of the penis. The meatus can be located anywhere on the glans, the penile shaft, base of the penis and at the penoscrotal junction. This is the common anomaly of the penis, it occurs in about 1 out of 300 infant boys and the incidence appears to be increasing.
The cause of this condition is multifactorial and includes maternal intake of progestin, advance maternal age and environmental factors. Hypospadia may associated with chordee and undescended testes.
Classification of hypospadias
URINARY TRACT INFECTION Is the inflammation of urinary epithelium usually caused by E.coli. It is common in women due to the shorter urethra and the proximity of the anal opening to the urethral orifice in females.
But in infant, the males are more common due to uncircumcised penis.
The urinary tract usually protected from pathogenic organism by the flushing action of urination and constant sloughing of the epithelium.
The acidity of normal urine also inhibits the growth of microorganism. There are two routes by which bacteria can reach the kidneys: 1. Through the bloodstream 2. As an ascending infection from the lower urinary tract.
PREDISPOSING FACTORS: Gender more common in female (above 60 years old and school age girls) Mechanical Factors e.g catheterization, sexual intercourse, kidney stones and improper use of tampons and douches.
Metabolic Disorders e.g the increased sugar content of urine in diabetes, making it conducive to bacterial growth. Anatomic abnormalities of the urinary tract cause obstruction or incomplete voiding of urine or reflux of urine.
ETIOLOGY: Common etiologic agent E. coli 50 to 80% of cases, gram negative found in anal and perineal region Staphylococcus saprophyticus Enterococci (enterococcus fecalis) Opportunistic pathogens (pseudomonia, protozoa, seratia)
Less common etiologic agent Bacteria S. Aureus, corynebacteria, lactobacilli Yeast candida Viruses adenovirus type 2
CLASSIFICATION OF UTI: Bacteria presence of bacteria in urine Asymptomatic bacteriuria significant bacteria with no evidence of clinical infection (usually defined as greater than 100,000 colony forming units <CFu) Symptomatic bateriuria accompanied by physical signs of urinary infection (dysuria, suprapubic pain, hematuria, fever)
Recurrent UTI repeated episode of bacteruiria of symptomatic UTI. Persistent UTI persistence of bacteriuria despite antibiotic treatment Febrile UTI bacteriuria accompanied by fever and other physical signs of UTI: presence of fever typically implies a pyelonephritis
Cystitis inflammation of the bladder Urethritis inflammation of the uretra Pyelonephritis inflammation of the upper urinary tract and kidneys. Urosepsis febrile urinary tract infection coexisting with systemic sign of bacterial illness: blood culture reveals presence of urinary pathogen.
Signs and symptoms: (1-24 months) Poor feeding Vomiting Failure to gain weight Excessive thirst Frequent urination Staining/screaming on urination
Foul smelling urine Pallor Fever Persistent diaper rashes Seizure (with or without fever) Dehydration Enlarged kidney or bladder
Treatment/Management: Objective of surgical correction. Enable child to void in standing position and direct stream voluntary and usual manner. Improve physical appearance of genitalia Produce a sexually adequate organ
Patient already has Hypospadia since birth. 1 week PTA, parents reported that the infant was not as alert and interactive as usual. He seems uncomfortable and sleeps somewhat restlessly. 5 days before the admission, patient became fussy and had poor oral intake. Parents noted that he is going to the breast more frequently but is sucking only for about 1-2 minutes at a time.
3 days PTA up to now, patient had 3 day history of on and off fever ranging from 37.5 up to 39 degrees Celcius. He was provided with TSB by his mother and was given Paracetamol every 4 hours. Rashes were present on patients perineal area. Parents reported that he is always crying upon his urination. He has not had any vomiting or diarrhea.
GRANDPARENTS
b 45 D 07 stroke b 47 HYPERTENSION
GRANDPARENTS
b 42 D 01 CHRONIC RENAL FAILURE b 45 DIABETES
AUNTS/UNCLES
b 69
HYPOSPADIA traeted by surgery
FATHER
b 75 CHAIN SMOKER (farmer)
MOTHER
b 79 DIABETIC b 76
AUNTS/UNCLES
b 73 D - 2010 PROSTATE CANCER
SIBLINGS
b 00 HYPOSPADIA (underwent 1st surgical operation)
PATIENT
b 11 HYPOSPADIA WITH UTI
LEGEND: - female
- male / - deceased
PARTS
NORMAL FINDINGS
Head
ACTUAL FINDINGS
INTERPRETA TION
ANALYSIS
head ; and has no tenderness ; no masses The patient had evenly distributed with no patches of hair loss.
Hair
Evenly distributed Evenly with no patches distributed of hair loss with no patches of hair loss
Normal
Eyes
Symmetrical eye brows, Intact eyelids, normally aligned eyeballs, Blink reflex are present, Clear cornea Iris.
Symmetrical eyebrows, Eyelids are intact , Clear cornea Iris (+) Blink Reflex
Normal
The patient had a symmetrical eyebrows eyelids are intact, Clear cornea Iris
PARTS
NORMAL FINDINGS
ACTUAL FINDINGS
INTERPRETATION
ANALYSIS
Ear
Normal
Mouth
Normal
Nose
Uniform color with nasal flaring, Nasal septum intact and in midline .
Uniform color with nasal flaring, Nasal septum intact and in midline .
Normal
Hands
Normal
Chest
Normal
NORMAL FINDINGS - Spine straight Has a symmetrical abdominal contour. Abdominal movements noted when inhaling
ACTUAL FINDINGS - Spine straight Has a symmetrical abdominal contour. Abdominal movements noted when inhaling
ANALYSIS The patient had a straight back The patient had symmetrical abdominal con tour. Movements noted when inhaling.
Reproductive (Penis)
The penis appears small ; the urethral opening is in the of tip the penis.
Hooded appearance of the penis; the end of the penis may be curved downward: Opening of the urethral meatus is on the underside of the penis
Abnormal
The patient had a frequent urination; The urethral opening is in the bottom of the penis
Normal
PARTS Skin
NORMAL FINDINGS skin has the rep of being soft, smooth, and sweetsmelling.
ACTUAL FINDINGS
INTERPRETA ANALYSIS TION Abnormal (perineal The patient rashes) looks have a like irritated perineal and red, rashes caus chances are ed by the he has it. His wearing of skin may also diapers be a little puffy and warm when you touch
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
INTERPRETATION
ANALYSIS
INTERPRETATION
ANALYSIS
Elimination
The client often experience difficulty in urinating and accompanied with high fever with irritability. Urine has a foul smelling odor.
The clients condition is well monitor by a physician. The client will have a lab test to check for any presence of bacteria in the urine, such as a urinalysis and a urine culture. Antibiotics may prescribe.
Functions of kidney usually diminish with age, but not significantly below normal levels, unless a disease process intervenes.
UTI is an infection in the urinary tract. Infections are caused by microbes organisms too small to be seen without a microscope. Bacteria are the most common cause of UTIs.
INTERPRETATION
ANALYSIS
Hygiene
The clients hygiene is maintained by daily bed bath and sponge bath. His sheets are changed every day or as needed.
Temperature is monitor. If fever is Increase Tepid Sponge Bath (TSB) will be the next step to decrease the fever. Frequent changing of diaper.
Ill people may not have the motivation or energy to attend to hygiene.
INTERPRETATION
ANALYSIS
The client lack of sleep and rest. Hes always restless and agitated when his disease or complication arises, especially during high fever.
The client is Abnormal usually on bed rest, he cried very often because of high fever, and especially during urination.
Illness that causes pain or physical distress can result in sleep problems.
ASSESSMENT
NORMAL
ACTUAL
INTERPRETATION ANALYSIS
APPEARANCE
abnormal
Cloudy there is presence of WBC and pus Red brown due to hematuria Restricted fluid intake indicates urine concentration Dehydration Presence of solid materials in urine
OSMOLALITY
50-1,400 mOsm/L
1,500 mOsm/L
SPECIFIC GRAVITY
1.001 1.030
1.060
pH
4.8 7.8
5.5
Normal
ASSESSMENT
NORMAL
ACTUAL
INTERPRETATION ANALYSIS
PROTEIN
Absent
Absent
Normal
Protein is not normally found in urine Kidney filters glucose and send into the bloodstream Normally ketone passed in the urine but large amount of ketones in urine may indicate diabetic ketoacidosis is present Usually bacteria that convert nitrate to nitrite is E.coli
GLUCOSE
Absent
Absent
Normal
KETONE
Absent to a few
Few
Normal
NITRITES
absent
present
abnormal
ASSESSMENT
ACTUAL 5
INTERPRETATION ANALYSIS Above normal Normal response of body to foreign body There is inflammation and injury in urinary tract that causes blood in urine Presence of bacteria There is no presence of cast because cast is formed in tiny tube of kidneys Subsequent with WBC
< 1-2
Above normal
BACTERIA
Absent to a few
CAST
Occassional
PUS
Absent
Present
pyuria
URINE CULTURE
1. Purpose 2. When it is ordered 3. Urine Sample Collection procedures 4. Proper Labeling and Storage 5. Sent to the Laboratory 6. Results
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS
INTERPRETATION
Abnormal
SUSCEPTIBILITY TESTING
ANTIMICROBIAL AGENT
SUSCEPTIBLE
INTERMEDIATE
RESISTANT
LEVOFLOXACIN
NORFLOXACIN ORFLOXACIN
97.3
97.8 97.7
0.1
0.1 0.4
2.5
2.1 1.9
NALIDIXIC ACID
96.5
<0.1
3.5
VIII. Pathophysiology
ASSESSMENT
DIAGNOSIS
PLANNING
RATIONALE
EVALUATIO N After four hours of nursing intervention , the client was relieved from urinary tract infection and rashes free as indicated on his relaxed facial expressions.
SUBJECTIVE:
Acute pain related to Umiiyak ang urinary anak ko alteration as habang umiihi manifested by sya as crying upon verbalized by urination, the mother of fever and the patient. facial expression of pain.
Short term goal: After 4 hrs of nursing intervention, the client will show some signs of comfort such as absent crying upon urination, and temperature will be in normal range
ASSESSMENT OBJECTIVE:
loud crying Facial expression of pain(brows lowered & drawn together, eyes tightly closed,& mouth open and squarish, nosebroadened/bulg ing Poor urine stream Poor feeding Foul smelling urine Persistent diaper rash
DIAGNOSIS
PLANNING Long term goal: After 1 week of nsg. Intervention , the client will be relieved from acute pain and the rashes will be deminished.
INTERVENTIO N Determine clients acceptable level of pain/pain control goals. Provide comfort measures. Record of urine I & O.
EVALUATION
To promote nonpharmacologi cal pain mngt. To measure if I & O is balanced/ Altered due to pain.
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N Dependent: Administer analgesics as indicted . Frequently encourage the family to complete the full prescribed course of the medications even though the child is feeling better
RATIONALE
EVALUATION
To maintain acceptable level of pain. To prevent developing stronger strain of any microorganis m
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N Evaluate/ Document clients response to analgesia with assist in transitioning/ altering drug regimen, based on patients needs. Collaborative: Discuss in SOs ways in which they can assist client with the precipitating condition
EVALUATION
ASSESSMENT SUBJECTIVE: Nilalagnat ang anak ko at laging umiiyak kapag umiihi sya as verbalized by the mother of the patient.
DIAGNOSIS
PLANNING SHORT TERM GOAL After 3 hours of nursing intervention the patients temperature will be subside from 38.1 to normal value.
INTERVENTIO N INDEPENDEN Performed tepid sponge bath Note for core temperature of the patient every 1 hour
RATIONALE
EVALUATION SHORT TERM GOAL After 3 hours of nursing intervention, the patients temperature was subsiding from 38.1 to normal value. .
Hyperthermia related to present medical condition as evidenced by the verbal report of the mothers patient OBJECTIVE: nilalagnat Flushed skin ang anak ko at warm to umiiyak kapag touch umiihi sya Facial grimace and Weak temperature appearance value of 38.1 VITAL SIGN: C. TEMP: 38.1 PR: 112 RR: 53
To decrease temperature by means of conduction To check if the patient temp is decreasing or increasing
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N Monitor and record all sources of fluid loss such as urine
RATIONALE
EVALUATION
LONG TERM GOAL After 4 days of nursing intervention the patient will relieve from discomfort during urination.
Monitor To assess if heart rate and theres any rhythm changes in patient cardiac rhythms Encouraged the mother of the patient to increased fluid intake of her child To prevent dehydration and to replace the fluid loss of the patient
LONG TERM GOAL: After 4 days of nursing intervention the patient was relieved from discomfort during urination. Therefore goal was met
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N Instruct the mother to dress the patient with thin cloth. Wrap the extremities of the patient Promote client safety Maintain well ventilated environment
RATIONALE
EVALUATION
To promote rapid decreasing of the temperature To minimize shivering To prevent stress and injury to the patient To promote comfort to the patient
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N DEPENDENT :
RATIONALE
EVALUATION
Give To facilitate antipyretics as fast recovery ordered. of the patient Administer oxygen as ordered. Administer bactrim as ordered To meet oxygen needs For treating infection
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N
RATIONALE
EVALUATION
COLLABORATI VE:
Get urine sample as ordered and submit to the laboratory for urinalysis and urine culture
ASSESSMENT Subjectiv e: Ano po bang mga dapat at hindi dapat gawin ko tungkol sa kondisyon ng anak ko? as verbalized by the mother of the patient.
DIAGNOSIS
PLANNING
RATIONALE
EVALUATION
Deficient knowledge related to unfamiliarity to the condition as evidence by inappropriate hygiene for the infant as well as inadequate environment al hygiene.
STG: After 1 hour of rendering nursing intervention the mother of the patient will be able to know the proper way of promoting good hygiene to his son.
To maintain the temperat ure on its normal range. To determin e changes in V/S especiall y the temp
After 1 hour of renderin g nursing interventi on the mother of the patient has known the proper way of promotin g good hygiene to his son.
ASSESSMENT
DIAGNOSI S
PLANNING
INTERVENTIO N Change diaper regularly. Demonst rate proper perineal care to the mother.
RATIONALE
EVALUATION
Objective : Improper changing of diaper Inappropr iate wiping of the anal and genital area. Perineal rashes
LTG:
After 3 days of rendering nursing intervention the patient will be able to feel more comfortable and the mother will be able to maintain proper hygiene of her son.
avoid rushes.
To let the mother of the patient know the proper way of cleaning the perineum
After 3 days of rendering nursing interventio n the patient will be able to feel more comfortabl e and the mother will be able to maintain proper hygiene of his son
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N
RATIONALE
EVALUATION
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTIO N
RATIONALE
EVALUATION
to fasten the healing process To avoid colonization of bacteria in the skin To know if the mother has gained enough knowledge regarding what she was asking before
X. Drug Study
Mechanism of Action
Pediatric patients 3mo Bacteriacidal : inhibits and older weighing synthesis of cell wall 40kg of sensitive organisms, causing URIs GU infx, skin cell death. and soft tissues infx--20 mg/kg/day PO in divided dose q12 hours. Severe infx--- 40 mg/kg/day PO in divided dose q12 hrs. or 45 mg/kg/day PO in divided dose q12 hrs.
Specific Indication
Side Effects
Nursing Implications
Infections due to: susceptible strains of haemophilus influenza e.coli neisserria gonorrhea streptococcus pneumonia producing staphylococci. prophylaxis against bacillus anthracis
lethargy Hallucinations Seizures Glositis Stomatitis Gastritis sore mouth furry tongue nausea and vomiting Diarrhea abdominal pain bloody diarrhea pdesudomemebranous colitis
Culture infected area prior to treatment; re-culture area if response is not as expected. Give in oral preparations only; amoxicillin is no taffected by food Continue therapy for at least 2 days after signs of infection have disappeared; continuation for 10 full days is recommended. Use corticosteroids or antihistamines for skin reaction. Report any side effects If GI upset occurs, take with meals
Mechanism of Action
Anti-bacterial
Like all beta-lactam antibiotics, cefixime binds to specific penicillin-binding This may be proteins (PBPs) administered as a located inside the single daily dose or bacterial cell wall, may be given in two causing the inhibition divided doses, as 4 of the third and last mg/kg every 12 hours. stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that cefixime interferes with an autolysin inhibitor.
Specific Indication
Side Effects
Nursing Implications
Suprax (cefixime) is indicated in the treatment of the following infections when caused by susceptible strains of the designated microorganisms: Uncomplicated Urinary Tract Infections caused by Escherria coli and Proteus mirabilis. Otitis Media caused by Haemophilus influenzae (beta-lactamase positive and negative strains), Moraxella (Branhamella) catarrhalis, (most of which are beta-lactamase positive) and S. pyogenes.
Stomach upset/pain, diarrhea, nausea, gas, headache, or dizziness may occur. Serious side effects such as: severe stomach/abdominal pain, persistent nausea/vomiting, yellowing eyes/skin, dark urine, unusual tiredness, new signs of infection bruising/bleeding, change in the amount of urine
Assess for infection at beginning of and throughout therapy. Obtain specimens for culture and sensitivity before initiating therapy. Observe patient for signs and symptoms of anaphylaxis ( rash, pruritus, laryngealedema wheezing) Take with meals.
Dose Frequency Action Tablets: 1 g. Capsules: 500 mg. Powder for suspension: 125, 250, 500 mg/teaspoon (5 ml). The recommended dose for children is 30 mg/kg/day as a single dose or two divided doses.
Mechanism of Action Bactericidal: inhibits the synthesis of bacterial cell wall , causing cells death.
Cefadroxil is used for treating infections of the urinary tract skin and softtissue, parhynx (t hroat), and tonsils (tonsilitis) caused by bacteria that are susceptible to its effect.
Specific Indication
Side Effects
Nursing Implications
This medication is a cephalosporin-type antibiotic used to treat a wide variety of bacterial infections (skin and urinary tract infections). It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for viral infections.
The most common side effects Take this medication exactly are: as directed by your doctor
Mechanism of Action Bactericidal: Inhibits synthesis of bacterial cell wall causing cell death.
Antibiotic
Specific Indication
Side Effects
Nursing Implications
CNS: headache Dizziness lethargy paresthesisas. GI: Nausea and vomiting anorrexia Hepatotoxicity HEMATOLOGIC: Bone marrow depression.
Take this drug w/ food. Complete the full course of this drug even if you feel better. This drug is prescribed for particular infection, DO NOT SELF-TREAT any other infections.
Mechanism of Action Bactericidal: Inhibits synthesis of bacterial cell wall causing cell death.
Antibiotic
Specific Indication
Side Effects
Nursing Implications
Respiratory tract infections caused by S. pnuemoniae group A beta hemolytic Sterptococci Skin and skin structure infection Otitis Media caused by S. Pnuemoniae
CNS: headache dizziness lethargy paresthesias GI: Nausea and vomiting diarrhea anorexia abdominal pain flatulence hepatotoxicity GU: nephrotoxicity HEMATOLOGIC: Bone marrow deppresion
Take this drug with food. Refrigerate suspension; discard after 14 days. Complete the full course of this drug even if the patient feels better. Report if severe diarrhea with blood or pus or mucus, rash or hives, DOB, unusual tiredness, fatigue, unusual bleeding bruising occurs.
Classification
Mechanism of Action Co-trimoxazole contains 2 active ingredients acting synergistically by blockade of 2 enzymes that catalyze successive stages in the biosynthesis of folinic acid in the microorganism. This mechanism usually results in bactericidal activity in vitro at concentrations at which the individual components are only bacteriostatic. In addition, cotrimoxazole is often effective against organisms that are resistant to one of the active component
Antibiotic
8 mg/kg/day TMP and 40 mg/kg/day SMZ PO in two divided dose every 12 hours
co
Specific Indication
Side Effects
Nursing Implications
GI upsets stomatitis skin reactions Renal and Urinary Tract tinnitus Infections erythema multiforme leukopenia Genital infections in both neutropenia sexes including urethritis, thrombocytopenia gonococcal. megaloblastic anemia pancytopenia or purpura GIT infections, including hyperkalemia typhoid and paratyphoid fever hypoglycemia and treatment of persistent serum sickness carriers, bacillary, dysentery, periarteritis nodosa cholera (as an adjunct to fluid allergic myocarditis and electrolyte replacement). purpura Skin and soft tissue infections; cholestasis pyoderma, furuncles, glossitis abscesses and infected convulsion wounds. vertigo Upper and Lower Respiratory Tract Infections
Treatment should be discontinued immediately at the first appearance of skin rash or any other serious adverse reaction Take this drug with food. Complete the full course of this drug even if the patient feels better. Report if severe diarrhea with blood or pus or mucus, rash or hives, DOB, unusual tiredness, fatigue, unusual bleeding bruising occurs
This medication is used to treat and prevent prevent diaper raash and other minor BRAND NAME(S): Desitin skin irritations (e.g., burning cuts, scrapes).
Mechanism of Action It works by forming a barrier on the skin to protect it from irritants/moisture
Specific Indication
Side Effects
Nursing Implications
No serious side effects other If skin irritation persists than skin irritation consult physician.
H YGIENE must be maintain. Y EARLY health examination such as routine analysis. P ROVIDE clean and Comfortable Environment. O UT PATIENT must have a regular check-up to the nearest health center for the development of the treatment. S ECURE appropriate intake of regular medications given by the physician. P ROMOTE deep breathing exercise for good circulation of blood and relaxation A - PPLY Zinc Oxide to relieves diaper rash, and also Multi-Vitamins for immunity. D OCTOR should be inform for any complications encountered. I NSTRUCT the mother or SOs of Pt. to limit his activity for 24hrs 48 hrs after discharge. A VOID use of Straddle toys walkers, or bicycle until it is approved by doctor. S PIRITUAL prayers to provide presence and Guidance of the Lord.
generic drugs.
T RAIN the mother to empty bladder completely with each void. H ELP the patients mother to be supportive regarding her sons condition.
U RINE culture should obtain after discharge. T HINK positive and everything will be put into place. I NCREASED FLUID INTAKE, give foods high in Fiber such as cereal or fruits to prevent constipation.
References:
8th Edition Wongs Nursing Care of Infants and Children Vol.1 (pp. 486-487) Microbiology & Parasitology by Bartolome Understanding pathophysiology 4th edition by Sue Hueeher Pathophysiology 4th edition by Barbara Bullock Maternal & Child by Pilliteri
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