PERSONAL DATA Name: Ms.

X Address: Caloocan City Birth Date: 05 February 1989 Age: 23 years old Sex: Female Place of Birth: Manila Nationality: Filipino Religion: Roman Catholic Date of Admission: 30 April 2012 Time of Admission: 01:00 PM Ward: 2/F Female Adult Infectious Disease and Tropical Medicine (IDTM) Department Hospital Number: 664401 Chief Complaint: fever, Admitting Diagnosis: DHF with warning signs Final Diagnosis: complicated urinary tract infection Date of Discharge: 03 May 2012 Time of Discharge: 10:20 AM

FAMILY BACKGROUND Ms. X lives wit HISTORY Family Health History

Past Health History

History of Present Illness Ms. X developed fever four days prior to consultation. She self-medicated with paracetamol every four hours for four times and fever subsided. Two days prior to admission, she developed fever with accompanying body weakness thus prompting consultation. Case was admitted as DHF with warning signs.

ANATOMY AND PHYSIOLOGY One of the most important systems of the body concerning homeostasis is the urinary system. It is located on the lower part of the torso specifically the abdomen. It is surrounded by the human digestive system anteriorly, the respiratory system superiorly, and the human vertebrae. Some parts of the urinary system lie in the pelvis, together with the reproductive organs. The Urinary System is a group of organs in the body concerned with filtering out excess fluid and other substances from the bloodstream. The substances are filtered out from the body in the form of urine. Urine is a liquid produced by the kidneys, collected in the bladder and excreted through the urethra. Urine is used to extract excess minerals or vitamins as well as blood corpuscles from the body. The urinary organs include the kidneys, ureters, bladder, and urethra. The urinary system works with the other systems of the body to help maintain homeostasis. The kidneys are the main organs of homeostasis because they maintain the acid base balance and the water salt balance of the blood. Kidney Kidneys are two bean-shaped organs located at the lumbar area of the back. The kidney is covered by a thin connective tissue capsule and consists of an outer cortex and medullary pyramid or papillae. Within these two regions are found the components of the

structural and functional unit of the kidney, the nephron. The nephron is composed of the glomerulus, a tuft of capillaries, which produces the glomerular filtrate, housed in the renal corpuscle; followed by a series of tubules, specialized for excretion and reabsorption. The outer most region of the kidney, which lies just below the convex surface of the organ, is the cortex, where three components of the nephron can be found. The renal corpuscles (or Bowman's capsules) containing glomeruli are surrounded by a labyrinth of proximal and distal convoluted tubules. The collecting tubules also penetrate the cortex, to connect with the distal convoluted tubules. These extensions are called medullary rays and represent the cores of the kidney lobules. The medullary portion of the kidney is organized as a single medullary pyramid (unilobar kidney) or multiple pyramids (multilobar kidney). Each pyramid of medullary tissue and its associated "cap" of cortical tissue are defined as a kidney lobe. The pyramids appear striated, due to the parallel alignment of the loops of Henle and collecting tubules. The nephron A nephron is the basic structural and functional unit of the kidney. The name nephron comes from the Greek word (nephros) meaning kidney. Its chief function is to regulate water and soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone. Each nephron has its own supply of blood from two capillary regions from the renal artery. Each nephron is composed of an initial filtering component (the renal corpuscle) and a tubule specialized for reabsorption and secretion (the renal tubule). The renal corpuscle filters out large solutes from the blood, delivering water and small solutes to the renal tubule for modification. Five parts: 1. The glomerulus, which is the blood kidney interface, plasma is filtered from capillaries into the Bowmans capsule.

2. The proximal convoluted tubule, which reabsorbs most of the filtered load, including nutrients and electrolytes. 3. The loop of Henle, which, depending on its length, concentrates urine by increasing the osmolality of surrounding tissue and filtrate. It has both ascending and descending limbs. 4. The distal convoluted tubule, which reabsorbs water and sodium depending on needs. 5. The collecting system, which collects urine for excretion. There are two types of nephrons, those localized to the cortex, and those extending into the medulla. The latter are characterized by long loops of Henle, and are more metabolically active. Ureters Each kidney has a ureter, an organ that drains urine which is collected at the renal pelvis. These two tiny tubes drain the urine to the bladder, where urine is stored. It has a transitional epithelium and a muscular (smooth muscle) layer, the lamina propia. Urinary bladder The urine is not directly drained to the external environment but rather is stored temporarily on a hollow organ, the urinary bladder. The urinary bladder is lined with transitional epithelium underlined by a collagenous lamina propria. A submucosa of elastic fibers and a muscular layer of three coats of smooth muscle permit expansion of the structure. Urethra When the bladder is full and needs emptying, the urine drains into the outside through the urethra, a hollow tube that drains urine to the orifice of the male penis or the female urethral orifice, between the clitoris and vaginal opening.

PATHOPHYSIOLOGY Urinary tract infection (UTI) is most common in females due to bathroom use. In the case of Ms. X, bacterial invasion may have brought about the disease. Suspected causative agents are usually Escherichia coli though laboratory results did not actually identify the CA. Ms. X says she does not know the underlying cause.

The urinary tract is most commonly sterile though the urethra may be contaminated with some bacteria. Urine acidity is one of the physiologic factors that makes the UT clean. When there is bacterial infection in the urethra, it causes urinary discomfort and pain including the suprapubic area. It may also cause fever and local inflammation. Since the client did not immediately go for consultation, bacterial proliferation ascended to cause a complicated UTI as the final diagnosis. This may be caused by several factors though not determined which is. Suspected cause maybe vesicoureteral reflux that allows urine in the lower tract to ascend. URINARY TRACT INFECTION (Readings) Bacterial UTIs can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency and urgency, dysuria, lower abdominal pain, and flank pain. Systemic symptoms and even sepsis may occur with kidney infection. Diagnosis is based on analysis and culture of urine. Treatment is with antibiotics. Among adults aged 20 to 50 yr, UTIs are about 50-fold more common in women. The incidence increases in patients > 50 yr, but the female:male ratio decreases because of the increasing frequency of prostate disease. 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. Mechanisms that maintain the tract's sterility include urine acidity, emptying of the bladder at micturition, ureterovesical and urethral sphincters, and various immunologic and mucosal barriers. About 95% of UTIs occur when bacteria ascend the urethra to the bladder and, in the case of acute uncomplicated pyelonephritis, ascend the ureter to the kidney. The remainder of UTIs are hematogenous. Systemic infection can result from UTI, particularly in the elderly. About 6.5% of cases of hospital-acquired bacteremia are attributable to UTI. Complicated UTI is considered to be present when there are underlying factors that predispose to ascending bacterial infection. Predisposing factors include urinary instrumentation (eg, catheterization, cystoscopy), anatomic abnormalities, and obstruction

of urine flow or poor bladder emptying. A common consequence of anatomic abnormality is vesicoureteral reflux (VUR), which is present in 30 to 45% of young children with symptomatic UTI (see Miscellaneous Infections in Infants and Children: Urinary Tract Infection in Children (UTI)). VUR is usually caused by a congenital defect that results in incompetence of the ureterovesical valve. It is most often due to a short intramural segment (the ureter normally transits the bladder wall at an angle; the resultant lengthy segment is more readily closed by muscular contraction than the shorter segment that occurs when the ureter passes straight through the wall). VUR can also be acquired in patients with a flaccid bladder due to spinal cord injury. Other anatomic abnormalities predisposing to UTI include urethral valves (a congenital obstructive abnormality), delayed bladder neck maturation, bladder diverticulum, and urethral duplications. Urine flow can be compromised by calculi and tumors. Bladder emptying can be impaired by neurogenic dysfunction (see Voiding Disorders: Neurogenic Bladder), pregnancy, uterine prolapse, cystocele, and prostatic enlargement. UTI caused by congenital factors presents most commonly in childhood. Most other factors are more common in the elderly. Uncomplicated UTI occurs without underlying abnormality or impairment of urine flow. It is most common in young women but also somewhat common in younger men who have unprotected anal intercourse, an uncircumcised penis, unprotected intercourse with a woman whose vagina is colonized with urinary pathogens, or AIDS. Risk factors in women include sexual intercourse, diaphragm and spermicide use, antibiotic use, and a history of recurrent UTIs. Even use of spermicide-coated condoms increases risk of UTI in women. The increased risk of UTI in women using antibiotics or spermicides probably occurs because of alterations in vaginal flora that allow overgrowth of Escherichia coli. In elderly women, soiling of the perineum due to fecal incontinence increases risk. Patients of both sexes with diabetes have an increased incidence and severity of infections. Etiology Commensal colonic gram-negative aerobic bacteria cause most bacterial UTIs. In relatively normal tracts, strains of E. coli with specific attachment factors for transitional epithelium of the bladder and ureters are the most frequent causes. The remaining gramnegative urinary pathogens are other enterobacteria, especially Klebsiella , Proteus mirabilis, andPseudomonas aeruginosa. Enterococci (group D streptococci) and coagulase-

negative staphylococci (eg, Staphylococcus saprophyticus) are the most frequently implicated gram-positive organisms. E. 50% of coli causes > 75% cases. The of community-acquired UTIs in all age groups; S. saprophyticusaccounts for about 10%. In hospitalized patients, E. coli accounts for about gram-negative species Klebsiella, Proteus, Enterobacter, and Serratia account for about 40%, and the gram-positive bacterial cocci Enterococcus faecalis and S. saprophyticus andS. aureus account for the remainder. Classification Urethritis: Infection of the urethra with bacteria (or with protozoa, viruses, or fungi) occurs when organisms that gain access to it acutely or chronically colonize the numerous periurethral glands in the bulbous and pendulous portions of the male urethra and in the entire female urethra. The sexually transmitted pathogens Chlamydia trachomatis (see Sexually Transmitted Diseases (STD): Chlamydial, Mycoplasmal, and Ureaplasmal Infections), Neisseria gonorrhoeae (see Sexually Transmitted Diseases (STD): Gonorrhea), Trichomonas vaginalis(see Sexually Transmitted Diseases (STD): Trichomoniasis), and herpes simplex virus (seeHerpesviruses: Herpes Simplex Virus (HSV) Infections) are common causes in both sexes. Cystitis: In women, sexual intercourse usually precedes uncomplicated cystitis (honeymoon cystitis). In men, bacterial infection of the bladder is usually complicated and generally results from ascending infection from the urethra or prostate or is secondary to urethral instrumentation. The most common cause of recurrent cystitis in men is chronic bacterial prostatitis. Acute urethral syndrome: Acute urethral syndrome, which occurs in women, causes dysuria and pyuria (dysuria-pyuria syndrome) due to bacterial urinary pathogens. Occasionally, it is caused by N. gonorrhoeae, TB, or fungal disease or by trauma or inflammation of the urethra. Patients with acute urethral syndrome have dysuria, frequency, and pyuria, but urine cultures are either negative or show colony counts that are < 105/mL, which is less than the traditional criterion for bacterial UTI. Asymptomatic bacteruria: Certain patients, primarily elderly women and patients with diabetes or those who require long-term use of indwelling catheters, have persistent bacteriuria with changing flora that is both asymptomatic and refractory to treatment.

WBC count in urine may be modestly elevated. Most of these patients are best left untreated because the usual result of treatment is the establishment of highly resistant organisms. Asymptomatic bacteriuria can also occur in pregnant women and may cause infection of the urinary tract, sepsis, low birth weight, spontaneous abortion, premature delivery (seePregnancy Complicated by Disease: Urinary Tract Infection in Pregnancy), and stillbirth, so treatment is indicated. Acute pyelonephritis: Pyelonephritis is bacterial infection of the kidney parenchyma. The term should not be used to describe tubulointerstitial nephropathy unless infection is documented. In women, about 20% of community-acquired bacteremias are due to pyelonephritis. Pyelonephritis is uncommon in men with a normal urinary tract. Although obstruction (eg, strictures, calculi, tumors, neurogenic bladder, VUR) predisposes to pyelonephritis, most women with pyelonephritis have no demonstrable functional or anatomic defects. Cystitis alone or anatomic defects may cause reflux. This tendency is greatly enhanced when ureteral peristalsis is inhibited (eg, during pregnancy, by obstruction, by endotoxins of gram-negative bacteria). Pyelonephritis or focal abscess may be due to hematogenous spread, which is infrequent and usually results from bacteremia with virulent bacilli (eg, Salmonella sp, S. aureus). Pyelonephritis is common in young girls and in pregnant women after instrumentation or bladder catheterization. The kidney usually is enlarged because of inflammatory PMNs and edema. Infection is focal and patchy, beginning in the pelvis and medulla and extending into the cortex as an enlarging wedge. Chronic inflammatory cells appear within a few days, and medullary and subcortical abscesses may develop. Normal parenchymal tissue between foci of infection is common. Papillary necrosis may be evident in acute pyelonephritis associated with diabetes, obstruction, sickle cell disease, pyelonephritis in renal transplants, pyelonephritis due to candidiasis, or analgesic nephropathy. Although acute pyelonephritis is frequently associated with renal scarring in children, similar scarring in adults is not detectable in the absence of reflux or obstruction. Symptoms and Signs In the elderly, UTIs are often asymptomatic. Elderly patients, and those with a neurogenic bladder or an indwelling catheter, may present with sepsis and delirium but without symptoms referable to the urinary tract.

When symptoms are present, they may not correlate with the location of the infection within the urinary tract because there is considerable overlap; however, some generalizations are useful. In urethritis, the main symptoms are dysuria and, primarily in males, urethral discharge. Discharge tends to be purulent when due to N. gonorrhoeae and whitish and mucoid when not. Cystitis onset is usually sudden, typically with frequency, urgency, and burning or painful voiding of small volumes of urine. Nocturia, with suprapubic and often low back pain, is common. The urine is often turbid, and gross hematuria occurs in about 30% of patients. A low-grade fever may develop. Pneumaturia (passage of air in the urine) can occur when infection results from a vesicoenteric or vesicovaginal fistula or from emphysematous cystitis. In acute pyelonephritis, symptoms may be the same as those of cystitis; one third of patients have frequency and dysuria. However, with pyelonephritis, symptoms typically include chills, fever, flank pain, colicky abdominal pain, nausea, and vomiting. If abdominal rigidity is absent or slight, a tender, enlarged kidney is sometimes palpable. Costovertebral angle percussion tenderness is generally present on the infected side. In children, symptoms often are meager and less characteristic (see Miscellaneous Infections in Infants and Children: Symptoms and Signs). Diagnosis

Urinalysis Sometimes urine culture

Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine. Urine collection: If a sexually transmitted disease (STD) is suspected, a urethral swab for STD testing is obtained prior to voiding. Urine collection is then by clean-catch or catheterization. To obtain a clean-catch, midstream-voided specimen, the urethral opening is washed with a mild, nonfoaming disinfectant and air dried. Contact of the urinary stream with the mucosa should be minimized by spreading the labia in women and by pulling back the

foreskin in uncircumcised men. The first 5 mL of urine is not captured; the next 5 to 10 mL is collected in a sterile container. A specimen obtained by catheterization is preferable in older women (who typically have difficulty obtaining a clean-catch specimen) and in women with vaginal bleeding or discharge. Many clinicians also use catheterization to obtain a specimen if evaluation includes a pelvic examination. Diagnosis in patients with indwelling catheters is discussed elsewhere (seeUrinary Tract Infections (UTI): Bacterial Urinary Tract Infections in Patients with Indwelling Bladder Catheters). Urine testing: Microscopic examination of urine is useful but not definitive. Pyuria is defined as 8 WBCs/L of uncentrifuged urine, which corresponds to 2 to 5 WBCs/highpower field in spun sediment. Most truly infected patients have > 10 WBCs/L. The presence of bacteria in the absence of pyuria, especially when several strains are found, is usually due to contamination during sampling. Microscopic hematuria occurs in up to 50% of patients, but gross hematuria is uncommon. WBC casts, which require special stains to differentiate from renal tubular casts, indicate only an inflammatory reaction; they can be present in pyelonephritis, glomerulonephritis, and noninfective tubulointerstitial nephritis. Dipstick tests also are commonly used. A positive nitrite test on a freshly voided specimen (bacterial replication in the container renders results unreliable if the specimen is not tested rapidly) is highly specific for UTI, but the test is not very sensitive. The leukocyte esterase test is very specific for the presence of > 10 WBCs/L and is fairly sensitive. In adult women with uncomplicated UTI with typical symptoms, most clinicians consider positive microscopic and dipstick tests sufficient; in these cases, given the likely pathogens, cultures are unlikely to change treatment but add significant expense. Cultures are recommended when symptoms are suggestive but urinalysis is nondiagnostic; for complicated UTI, including UTI in patients with diabetes, immunosuppression, recent hospitalization or urethral instrumentation, or recurrent UTI; for patients > 65 yr; and perhaps for patients with symptoms of pyelonephritis. All prepubertal children should have a urine culture when a UTI is suspected. Urine should be cultured as soon as possible or stored at 4C if a delay of > 10 min is expected. Samples contaminated with large numbers of epithelial cells are unlikely to be helpful. An uncontaminated specimen should be obtained for culture. Criteria, based on the guidelines

of the Infectious Diseases Society of America, (see the Infectious Diseases Society of America's Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults) for bacteriuria are:

Among women with suspected asymptomatic bacteriuria, 2 consecutive clean-catch voided specimens from which the same bacterial strain is isolated in colony counts of > 105/mL

Among women with suspected acute urethral syndrome, a clean-catch voided specimen from which a single bacterial species is isolated in colony counts from 102 to 104/mL Among men, a clean-catch voided specimen from which a single bacterial species is isolated in colony counts > 105/mL Among women or men, a catheter-obtained specimen from which a single bacterial species is isolated in colony counts of > 102/mL Occasionally, UTI is present despite lower colony counts, possibly because of prior

antibiotic therapy, very dilute urine (specific gravity < 1.003), or obstruction to the flow of grossly infected urine. Repeating the culture improves the diagnostic accuracy of a positive result, ie, may differentiate between a contaminant and a true positive result. Infection localization: Clinical differentiation between upper and lower UTI is impossible in many patients, and testing is not usually advisable. When the patient has high fever, costovertebral angle tenderness, and gross pyuria with casts, pyelonephritis is highly likely. The best noninvasive technique for differentiating bladder from kidney infection appears to be the response to a short course of antibiotic therapy. If the urine has not cleared after 3 days of treatment, pyelonephritis should be sought. Symptoms similar to those of cystitis and urethritis can occur with vaginitis, which may cause dysuria from the passage of urine across inflamed labia. Vaginitis can often be distinguished by the presence of vaginal discharge, vaginal odor, and dyspareunia. Other testing: Seriously ill patients require evaluation for sepsis, typically with CBC, electrolytes, BUN, creatinine, and blood cultures. Patients with abdominal pain or tenderness are evaluated for other causes of an acute abdomen (see Acute Abdomen and Surgical Gastroenterology: Acute Abdominal Pain). Pyuria without bacteriuria can be present with appendicitis, inflammatory bowel disease, and other extrarenal disorders.

Most adults do not require assessment for structural abnormalities unless infections recur or are complicated, nephrolithiasis is suspected, there is painless hematuria or new renal insufficiency, or fever persists for 72 h. Imaging choices include ultrasonography, CT, and IVU. Occasionally, voiding cystourethrography, retrograde urethrography, or cystoscopy is warranted. Urologic investigation is not routinely needed in women with symptomatic or asymptomatic recurrent cystitis, because findings do not influence therapy. Children with UTI often require imaging (see Miscellaneous Infections in Infants and Children: Urinary tract imaging). Treatment

Antibiotics Occasionally surgery (eg, to drain abscesses, correct underlying structural abnormalities, or relieve obstruction)

All forms of bacterial UTI require antibiotics. Obstructive uropathy, anatomic abnormalities, and neuropathic urinary tract lesions such as compression of the spinal cord usually require surgical correction. Catheter drainage of an obstructed urinary tract aids in prompt control of UTI. Occasionally, a renal cortical abscess or perinephric abscess requires surgical drainage. Instrumentation of the lower urinary tract in the presence of infected urine should be deferred if possible. Sterilization of the urine before instrumentation and antibiotic therapy for 3 to 7 days after instrumentation can prevent life-threatening urosepsis. For patients with troublesome dysuria, phenazopyridine

may help control symptoms until the antibiotics do (usually within 48 h). Urethritis: Sexually active patients with symptoms are usually treated presumptively for STDs pending test results. A typical regimen is ceftriaxone 125 mg IM plus either azithromycin 1 g po once or doxycycline 100 mg po bid for 7 days. For non-STD urethritis in men,trimethoprim/sulfamethoxazole (TMP/SMX) or a fluoroquinolone is given for 10 to 14 days; women are treated with a regimen for cystitis.

Cystitis: A 3-day oral course of TMP/SMX or a fluoroquinolone effectively treats acute cystitis and eradicates potential bacterial pathogens in vaginal and GI reservoirs. Singledose therapy results in higher recurrence rates and is not recommended. Longer courses of therapy (7 to 14 days) are prescribed for patients with a history of recent UTI, diabetes mellitus, or symptoms lasting > 1 wk. If pyuria but not bacteriuria is present in a sexually active woman, then C. trachomatisurethritis is diagnosed presumptively, and appropriate treatment is given to the patient and her sex partner. If symptoms recur and culture reveals an organism sensitive to the drugs used for 3-day antibiotic therapy or if pyelonephritis is suspected, a 14-day course of TMP/SMX or a fluoroquinolone is given as for pyelonephritis. Acute urethral syndrome: Acute urethral syndrome with pyuria is treated with doxycycline

100 mg po bid for 7 to 10 days or TMP/SMX 160/800 mg po bid for 3 days. If neither pyuria nor bacteriuria is present, antibiotics are not indicated. A course of urinary analgesics may be appropriate. Asymptomatic bacteriuria: Ordinarily, asymptomatic bacteriuria in patients with diabetes, elderly patients, or patients with chronically indwelling bladder catheters should not be treated. However, asymptomatic bacteriuria in pregnant women is actively sought and treated as a symptomatic UTI, although many antibiotics cannot be safely used. Oral lactams, sulfonamides, and nitrofurantoin are considered safe in early pregnancy, but sulfonamides should be avoided near parturition because of a possible role in the development of kernicterus. Treatment may also be indicated in asymptomatic UTI in patients with neutropenia, patients with recent renal transplantation, patients scheduled for instrumentation of the urinary tract (after removal of a bladder catheter that has been in place for > 1 wk), young children with gross VUR, and patients with frequent UTI symptoms from a struvite calculus that cannot be removed. Therapy typically consists of an appropriate antibiotic (based on

culture results) for 3 to 14 days or long-term suppressive therapy for untreatable obstructive problems (eg, calculi, reflux). Acute pyelonephritis: Outpatient treatment with oral antibiotics is possible if the patient is reliable in following medical advice and is immunocompetent and has no nausea or vomiting, signs of volume depletion, or evidence of septicemia. Typical regimens are 14 days of TMP/SMX 160/800 mg po bid or ciprofloxacin 500 mg po bid. Otherwise, patients should be hospitalized and given parenteral therapy selected on the basis of local sensitivity patterns of the most common strains. Common regimens include ampicillin

plus gentamicin, TMP/SMX and a fluoroquinolone, and broad-spectrum cephalosporins (eg, ceftriaxone).Aztreonam, -lactam/-lactam inhibitor combinations (ampicillin/sulbactam,ticarcillin/clavulanate, piperacillin/tazobactam),and imipenem/cila statin are generally reserved for patients with more complicated pyelonephritis (eg, obstruction, calculi, resistant bacteria, hospital-acquired infection) or recent urinary tract instrumentation. If parenteral therapy is required, it is continued until defervescence and other signs of clinical improvement occur. In > 80% of patients, improvement occurs within 72 h. Oral therapy can then begin, and the patient can be discharged for the remainder of the 14-day treatment course. For complicated cases, prolonged antibiotic suppression may be needed as well as urologic correction of anatomic defects. When pyelonephritis is diagnosed during pregnancy, hospitalization and parenteral therapy with a -lactam with or without an aminoglycoside is appropriate. Prevention In women who experience 3 UTIs/yr, voiding immediately after sexual intercourse and avoiding use of a diaphragm may be helpful. Drinking cranberry juice (50 mL of concentrate or about 300 mL of juice daily) reduces pyuria and bacteriuria. Increasing total fluid intake may also help. If these techniques are unsuccessful, low-dose oral antibiotic prophylaxis greatly reduces the incidence of recurrent UTIseg, TMP/SMX 40/200 mg once/day or 3 times/wk,nitrofurantoin (macrocrystals) 50 or 100 mg once/day, or a fluoroquinolone

(eg,ciprofloxacin, norfloxacin, ofloxacin, lomefloxacin,

enoxacin).

Long-term

use

ofnitrofurantoin increases the risk of adverse effects and is contraindicated in patients with renal failure. Postcoital TMP/SMX or a fluoroquinolone may be effective. If UTI recurs after 6 mo of this therapy, prophylaxis may be reinstituted for 2 or 3 yr. Because of potential injury to a fetus, users of fluoroquinolones should also use effective contraception. Some antibiotics (macrolides, tetracyclines, rifampin

, metronidazole, penicillins, and TMP/SMX) interfere with the effectiveness of oral contraceptives by interrupting the enterohepatic recycling of estrogen or by inducing hepatic estrogen metabolism. Women who use oral contraceptives should use barrier contraceptives while they are taking these antibiotics. In pregnant women, effective prophylaxis of UTI is similar to that in nonpregnant women. Appropriate patients include those with acute pyelonephritis during a pregnancy, patients with> 1 episode (despite treatment) of UTI or bacteriuria during pregnancy, and patients who required prophylaxis for recurrent UTI before pregnancy. In postmenopausal women, antibiotic prophylaxis is similar to that described previously. Additionally, topical estrogen therapy markedly reduces the incidence of recurrent UTI in women with atrophic vaginitis or atrophic urethritis. DEVELOPMENTAL DATA Erick Eriksons Theory of Development Erick Erikson envisions life as a sequence of levels of achievements. He described 8 stages of development. Each stage signals a task that must be achieved. In his view for each stage of development, some kind of psychosocial crisis slightly occurs. If a person is provided with a social and psychological environment that is conducive to development, he will be able to deal adequately with the crisis and problems at each stage. If he fails to develop the strengths needed at each stage, he will subsequently find difficulty in dealing with psychosocial crisis in the succeeding stages of development.

Our patient is in the early adulthood period. Psychosocial Stage 6 - Intimacy vs. Isolation

This stage covers the period of early adulthood when people are exploring personal relationships. Erikson believed it was vital that people develop close, committed relationships with other people. Those who are successful at this step will develop relationships that are committed and secure.

Remember that each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important to developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. The patient is still exploring the life with having a life partner and she says she has not yet had the problem of being raised up until of being a mother.

Havighurst Developmental Task The rate of a persons growth and development is highly individualized. However, the sequence of growth and development is predictable. Robert Havighurst believed that learning is the basic of life and that people continue to learn throughout life. This simple age-grading stops in our culture somewhere around sixteen to twenty. It is like reaching the end f the ladder and stepping off onto a new, strange cloud-land with giants and whiche to be circumvented and the goose that lays the golden egges to be captured if only one can discover the know-how. 1) Select ing a mate: Until it is accomplished, the task of finding a marriage partner is at once the most interesting and the most disturbing of the tasks of early adulthood. 2) Learning to live with a marriage partner: After the wedding there comes a period of learning how to fit two lives together. In the main this consists of learning to express and control one's feeling--anger, joy, disgust, live --so that one can live intimately and happily with one's spouse.

3) Starting a family: To have a first child successfully. 4) Rearing children: With the gaining of children the young couple take over a responsibility far greater than any responsibitily they have ever had before. Now they are responsible for human life that is not their own. To meet this responsibility they must learn to meet the physicial and emotional needs of young children. This means learning how to manage the child, and also learning to adapt their own daily and weekly schedules to the needs of growing children. 5) Managing a home: Family life is build around a physical center, the home, and depends for its success greatly upon how well-managed this home is. Good home management is only partly a matter of keeping the house clean, the furniture and plumbing and lighting fixtures in repair, having meals well-cooked, and the like. 6) Getting started in an occupation: This task takes an enormous amount of the young man's time and energy during young adulthood. Often he becomes so engrossed in this particualr task that he neglect others. He may put off finding a wife altogether too long for his own happiness. 7) Taking on civic responsibility: To assume responsibility for the welfare of a group outside of the family--a neighborhood or community group or church or lodge or political organization. 8) Finding a congenial social group: Marriage oftne imvolves the breaking of soical ties for one or both young people, and the forming of new friendships. Either the man or the woman is apt to move away from former friends. In any case, whether old friendships are interrupted by distance or not, the young couple faces something of a new task in forming a leisure-time pattern and finding others to share it with. The young man loses interest in some of his former bachelor activities, and his wife drops out of some of her purely feminine associations.

PATTERNS OF FUNCTIONING

Eating Pattern BEFORE ILLNESS DURING ILLNESS

Ms. X is not choosy concerning to foods. In During her hospitalization, Ms. X was able to fact, she used to eat a lot at home. She eat but not able to consume her entire usually eats breakfast at around 6 in the hospital ration. She is on full diet except morning and is composed of either 1 piece with dark-colored foods. of boiled or scrambled egg, 1 piece of dried She eats her breakfast at 7 am, with the fish and 1 cup of rice or bread. At lunch at usual Filipino table breakfast, her lung at about 12 noon, she consumes 1 cup of rice 11am with 1 cup rice, a vegetable and meat with 1 piece of fried fish or a bowl of paksiw dish, similar with the 6pm dinner. or either vegetable. For dinner, she has vegetable or meat with a serving of rice. She eats her snacks at about 9:30 in the morning and 3 in the afternoon. She has no eating rituals. Analysis: There are no alterations on the patients ability to take food, but there are modifications of diet due to restriction of several foods, like those with dark colors which may interfere with fecalysis exams. Drinking Pattern BEFORE ILLNESS Ms. X is fond of drinking sodas as well as with water. She drinks about 3 8oz bottles of soda and around 1.5 liters of water a day. DURING ILLNESS During her stay at the hospital, Ms. X did not consume sodas, only water which maybe 2.2 liters a day.

Analysis: In the drinking pattern, there is no intake of soda but only water, which increase in intake is necessary to replenish lost fluids and to prevent dehydration as well as comfort measure in the presence of fever. Bladder Pattern

BEFORE ILLNESS

DURING ILLNESS

Ms. X stated that she urinates 6 times a day Ms. X urinates into dark-amber urine during into yellow colored urine in moderate the first two days. She urinates the same amount. She urinates 3-4 times at daytime, 1 amount and feels moderate pain during the in the evening and before bedtime. She second day. She tells us that there is a slight urinates about 500mL a day. odor of the urine. Analysis: there was a change at the urine color maybe associated with the presence of the infection. Output was the same amount as before illness. The odor maybe due to the bacterial infection. Bowel Elimination Pattern BEFORE ILLNESS DURING ILLNESS

Ms. X usually defecates once a day, seldom She stated that she defecates once a day at twice. She has an output of yellow brown, the hospital, yellow brown to orange brown soft feces. It is slightly odorous and in color, in moderate amount and seems moderate in amount. dryer than before illness. Analysis: There is no great alteration in the bowel elimination pattern, only that the client just defecated once and the stool is dryer which maybe a presenting sigh of dehydration. Bathing Pattern BEFORE ILLNESS DURING ILLNESS

She bathes twice a day in the early morning While at the hospital, Ms. X did not take a and at evening. She uses shampoo and body bath on the first day but she did on the soap. She prefers cool water to bathe with. second day. She bathe with shampoo and with soap in a shorter period than before illness. Analysis:Ms. X did not greatly alter her bathing pattern except during the first day and when she bathe with a shorter period at the hospital since she cannot tolerate prolonged standing or sitting due to dizziness. Sleeping Pattern

BEFORE ILLNESS

DURING ILLNESS

Ms. Xx is not fond of siesta. Instead, she Ms. X takes a nap at daytime for around 10-15 would turn her TV on. Before bed, she would minutes, sleeps at 8pm and wakes up at 6am watch primetime soaps. She goes to bed at since she has no TV at the hospital. She uses 9pm and wakes up at 5 or 6am. she sleeps her electric fan in sleeping the whole night, with her electric fan on the whole night. She and also uses it the whole day. has no rituals before sleeping. Analysis: she has a longer period of sleeping at the hospital and takes her nap. She uses her electric fan to dissipate heat in sleeping.

LEVEL OF COMPETENCIES Physical aspect BEFORE ILLNESS meeting her self-care needs and other tasks. DURING ILLNESS because the child is at home. She cannot

Ms. X can do her daily activities such as She was not able to look after her child She has no job and keeps at home. She takes ambulate without assistance since she feels care of her child most of the time as a dizzy most of the time. mother. Analysis: there is a change since during illness she was not able to do her things anymore. Mental/ Intellectual aspect BEFORE ILLNESS the usual general knowledge a 23 year old has. Analysis: There are no alterations in the mental competency of the patient. Social aspect BEFORE ILLNESS DURING ILLNESS DURING ILLNESS

She was a college student before. She knows Her intellectual functioning was as before.

Ms. X is a person who is fond of socializing According to her, her attitude towards with She others. is a She cheerful is used and to having communicating with others was as before. conversations with their neighbourhood. interpersonal individual. Analysis: Despite being ill, Ms. X was still able to socialize as usual. This signifies that the presence of his illness did not hinder him to mingle well with others. Spiritual aspect BEFORE ILLNESS Catholic religion. She says she prays but in God. seldom attends the church and other religious activities. Analysis: Her faith in God was still steadfast though she is ill. Emotional aspect BEFORE ILLNESS DURING ILLNESS DURING ILLNESS

She is religiously affiliated with the Roman She prays usually and has her steadfast faith

Ms. X is a cheerful person. She is usually Ms. X is still tries to smile though she is ill. happy satisfied with her life with her family. Her emotions are not so much affected She says she is never sad since there is no except her longing to see her child again. usual problem within the family except when financial crisis occurs. Analysis: She is still able to emote naturally and correctly. DIAGNOSTIC PROCEDURES

MEDICAL MANAGEMENT

Intravenous fluid Therapy It is an efficient method for supplying fluid directly into the intravenous fluids compartments and to replace deficits of the total body water, to restore volume of blood components and provide avenue for administration of Intravenous medication. Purposes: It aims to maintain homeostasis, functioning/maintaining and to replace body sources of fluid, electrolytes, vitamin, carbohydrates, fats and calories in the client to restore acid-base balance, and restore volume of blood components. The IV fluid of our patient is D5NM D5NM Normosol-M Hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection. - Nonpyrogenic, parenteral fluid, electrolyte and nutrient replenisher - Each 100 mL contains dextrose,hydrous 5 g, sodium chloride, 234 mg, potassium acetate, 128 mg and magnesium acetate, anhydrous 21 mg. May contain hydrochloric acid for pH adjustment. Nursing Responsibilities: 1. Ask the clients name to ensure safety for identity. 2. Check the IV solution against the physicians orders for the type, amount and rate of flow. To ensure efficiency and accuracy. 3. Re-emphasize the purpose of the IVF therapy to the patient and significant others to gain cooperation and to increase their awareness about the procedure, likewise gaining the patients cooperation. 4. Check the fluids and equipments to be used for infusion for any discoloration, cloudiness, presence of particles, cracks of bottle, punctured bottle, IV tubing and catheters discoloration to identify possible indications of expiration or contamination. 5. Clean the infusion site using cotton balls with alcohol to prevent infection and promote aseptic technique.

6. Regulate IVF to the desired flow rate. In order to meet necessary fluid and electrolyte needed by the body within the specified length of infusion as well as to prevent circulatory overload. 7. Label the IV bottle to ensure the proper IV Fluid given to the patient. 8. Position the arm with the site of IV infusion comfortably to maintain patency of IV line. 9. Instruct the client to avoid unnecessary movements especially on the infusion site to prevent dislodging of the needle and infiltration. 10. Check the patency of IV and discontinue immediately if sign of infiltration is present to prevent thrombophlebitis. 11. Make sure that the infusion site is free from contamination to prevent infection and phlebitis. 12. Change the solution container before it is completely emptied to prevent air embolism. 13. . Document the type of IV solution infused, its volume, its desired flow rate, the date and time it was infused and consumed. This would serve as a record or for legal purposes.

Oxygen Inhalation Therapy Oxygen therapy is the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care. Oxygen is essential for cell metabolism, and in turn, tissue oxygenation is essential for all normal physiological functions. Nasal Cannula The nasal cannula (NC) is a low flow system because it administers oxygen while the patient also inspires room air. The actual dose of oxygen received by the patient will vary depending on patients respiratory pattern. This device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help. This device consists of a plastic tube which fits behind the ears, and a set of two prongs which are placed in the

nostrils. Oxygen flows from these prongs. The nasal cannula is connected to an oxygen tank, a portable oxygen generator, or a wall connection in a hospital via a flowmeter. The nasal cannula carries 16 litres of oxygen per minute. Type: Nasal Cannula Regulation: 3 liters per minute Purpose: This is done to our patient to provide sufficient oxygen to the body and specifically for the utilization of the cells, and prevent damage to vital organs resulting from inadequate oxygen supply. It is designed to help restore or improve breathing due to difficulty of breathing. Nursing Responsibilities: 1. Verify doctors order and identify the patient to prevent errors in giving oxygen therapy. 2. Re-emphasize the procedure to the patient and its purpose to reduce the anxiety of the patient and to gain cooperation. 3. Prepare the materials needed to save time and energy during the oxygen administration. 4. Wash hands/hand hygiene to reduce the transmission of microorganisms. 5. If using humidity, fill humidifier to fill line with distilled water and close container to prevent drying of patients airway and thins any secretions. 6. Attach humidifier to oxygen flow meter to allow the oxygen to pass through the water and become humidified. 7. Attach the oxygen tubing and nasal cannula to the flow meter and turn it onto the prescribed flow rate (3 lpm). Rates above 6 liters per minute are not efficacious and can dry the nasal mucosa. 8. Check for bubbling in the humidifier. It ensures proper functioning. 9. Feel for air from the prongs to check for patency of the tubing.

10. Place the nasal prongs in the patients nostrils. Secure the cannula in place by adjusting the tubing around the patients ear and using the slip ring to stabilize it under the patients chin. To keeps the delivery system in place so that the patient receives the amount of oxygen ordered. 11. Position the patient in High Fowlers Position to promote lung expansion thereby promoting oxygenation. 12. Ensure patent airway and check for proper flow rate every 1 hour to make sure that the patient is receiving proper amount of oxygen needed. 13. Assess patients nostril every 8 hours. If the patient complains of dryness or has signs of irritation, use sterile lubricant to keep mucous membrane moist. Check humidifier if not already in place. Dry membranes are more prone to breakdown by frictions or pressure from nasal cannula. 14. Monitor vital signs, oxygen saturation, and patients condition every one hour. It detects any untoward effects from therapy. 15. Wean patient from oxygen as soon as possible using standard protocol. Oxygen is not without side effects and should be used only as long as needed. Problems with reimbursement may develop if criteria for therapy are not met. 16. Document the procedure for legal purposes. Intake and Output Monitoring Intake.Intake is any measurable fluid that goes into the patient's body. Intake includes fluids (such as water, soup, and fruit juice) and "solids" composed primarily of liquids (such as ice cream and gelatin) that are taken by mouth (orally), fluids that are introduced by IV, and fluids that are introduced by irrigation (through a tube). Output.Output is any measurable fluid that comes from the body. Water given off in the form of perspiration and water vapor (exhaled breath) is also output, but it is not recorded on the patients chart, since it cannot be accurately measured. (An adult usually looses about 500 milliliters (ml) a day through perspiration and moisture exhaled in breathing.) The major forms of output recorded on the worksheet are urine, drainage, vomitus (matter vomited), and stools (fecal discharge from the bowels).

Purpose: This is done to our patient to assess accurately and quantitatively his intake and output. Nursing Responsibilities: 1. Verify doctors order to confirm the procedure to be done to the patient. 2. Re-emphasize the procedure and its purposes to the patient and watcher to gain compliance. 3. Provide an accurate calibrated glass to the patient and watcher for oral fluid intake, and instruct on how to use it to have accurate measurement for the patients fluid intake. 4. Provide an empty IV bottle to patient for urine output measurement to monitor accurately the patients urine output. 5. Instruct watcher to record all the fluids taken by the patient as well as the patients urine output (provide a notebook and ballpen) for proper monitoring of patients oral intake and urine output. 6. Document all the measurements of oral fluid intake, clysis, and urine output in the I& O sheet accurately for legal purposes. 7. Record and notify physician for noticeable alterations in urine output such as the color, amount and frequency to have immediate action and prevent further complications.

Diet Therapy Diet therapy is an effective method of healing, especially when utilized as a complementary method of care. Diet therapy is used for people who are trying to increase or decrease their body weight, have a sensitive digestion system that may be prone to allergies, who may not be able to digest certain foods, are trying to produce specific effects in their body (like regulating blood sugar), or are trying to overcome vitamin or mineral deficiencies.

Diet as tolerated except dark colored foods Nursing Responsibilities: 1. Verify doctors order and identify the patient to prevent errors in giving special diet. 2. Re-emphasize the purpose of the diet to the patient to gain cooperation. 3. Indicate her diet in the diet list or refer to the dietitian for proper instruction of the diet to be sure that the patient is served with her prescribed diet. 4. Monitor the patient if she is eating the prescribed diet to ensure that the patient is complying with the prescribed diet. 5. Provide meals/foods served attractively and encourage the significant others to use variety of flavoring to enhance her appetite or improve the taste of the food and encourage the patient to accept the diet. 10. Document the type of diet indicated for the patient in the nurses notes for legal purposes. Drug Study Drug Name: Paracetamol (Biogesic) Classification: analgesic Dosage, Route, Frequency: 1 tablet PO every four hours Adverse effects: GI discomfort, nausea, dizziness, vomiting Nursing responsibilities: Check that the patient is not taking any other medication containing paracetamol. For children who may refuse medicine off a spoon try using a medicine syringe to squirt liquid slowly into the side of the child's mouth or use soluble paracetamol mixed with a drink. Some children may be happy to take one paracetamol product but dislike the taste of another. There are no known harmful effects when used during pregnancy.

Small amounts may pass into breast milk. However, there are no known harmful effects when used by breastfeeding mothers. Alcohol increases the risk of liver damage that can occur if an overdose of paracetamol is taken. The hazards of paracetamol overdose are greater in persistent heavy drinkers and in people with alcoholic liver disease.

Evaluate therapeutic response.

Drug Name: Cefuroxime sodium Classification: antibiotic, antiinfective (cephalosporin) Dosage, Route, Frequency: 750gm IM OD Adverse effects: Nursing responsibilities:

Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Inspect IM and IV injection sites frequently for signs of phlebitis. Report onset of loose stools or diarrhea. Although pseudomembranous colitis. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

Drug Name: Potassium chloride (Kalium durule) Classification: Potassium replacement drug Dosage, Route, Frequency: 1 tablet PO TID Adverse effects: GI discomfort, nausea, gas vomiting Nursing responsibilities: Watch out for levels of potassium electrolyte level to prevent hyperkalemia. Observe 10 rights of giving medication.

Watch out for possible adverse reaction of the patient. Drug Name: Ferrous sulfate Classification: Iron supplement

Dosage, Route, Frequency: 1 tablet PO OD Adverse effects: nausea, epigastric pain, vomiting, constipation, diarrhea, black stools, anorexia Nursing responsibilities: Obtain baseline assessment of patients iron deficiency before starting therapy. Evaluate hemoglobin, hematocrit, and reticulocyte count during therapy. Be alert for adverse reactions and drug interactions. Assess patients and familys knowledge of drug therapy.

NURSING CARE MANAGEMENT Nursing Diagnosis Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood as manifested by decreased WBC, platelet and hemoglobin count and decreased capillary refill time. Nursing Goal After 3 hours of rendering nursing interventions the patient will able to demonstrate behaviors to improve circulation as manifested by normal level of WBC, platelet and hemoglobin count. Nursing Intervention 1. Monitor vital signs every 30 minutes to obtain baseline data. 2. Assess patient condition to assess contributing factors. 3. Note presence of bleeding to determine risk for anemia. 4. Encourage quiet and restful atmosphere to promote comfort and decrease tissue oxygen demand. 5. Instruct to avoid tiring activities to decrease cardiac work load. 6. Administer medications to treat underlying cause. Nursing Evaluation

After 3 hours of rendering nursing interventions the patient was able to demonstrate behaviors to improve circulation as manifested by normal level of WBC, platelet and hemoglobin count.

Nursing Diagnosis Hyperthermia related to increased metabolic rate as evidenced by increased in body temperature higher than normal range, flushed skin and warm to touch. Nursing Goal After 3 hours of rendering nursing interventions the patients temperature will decrease into normal range (36.4 37.6 oC), absence of flushed skin, sweating and no longer warm to touch. Nursing Interventions 1. Monitor v/s to obtain baseline data. 2. Provide tepid sponge bath every 15 minutes and apply local ice packs in axilla to reduce body temperature. 3. Instruct client to have bed rest to reduce metabolic demand. 4. Administer antipyretics to restore normal body temperature. 5. Reassess temperature every 15 minutes to determine effectiveness of interventions done. Nursing Evaluation After 3 hours of rendering nursing interventions the patients temperature decreased into normal range (36.9 oC), absence of flushed skin, sweating and no longer warm to touch.

Nursing Diagnosis Deficient Fluid Volume: less than body requirements related to increased capillary permeability, vomiting and fever as manifested by sudden weight loss, weakness, and poor skin turgor. Nursing Goal After 3 hours of rendering nursing intervention the patients body fluid volume will be returned to normal as manifested by weight gain, normal skin turgor and already felt a little stronger. Nursing Interventions 1. Provide adequate hydration according to the needs of the body. 2. Administer/monitor IV fluids and electrolytes as indicated to correct fluid and electrolyte imbalances and to prevent cardiac dysrhythmias. 3. Instruct client to increase oral fluid intake to prevent dehydration. 4. Observation and recording of intake and output to monitor improvements of the patients fluid volume. 5. Monitor laboratory values such as electrolyte/blood, urine specific gravity to check an improvement in fluid volume. The lower the specific gravity of the urine, the more is the body fluid. Nursing Evaluation After 3 hours of rendering nursing intervention the patients body fluid volume was be able to return to normal as manifested by weight gain, normal skin turgor and already felt a little stronger.