CASE STUDY OF MRS O.

P WITH URINARY TRACT

INFECTION DURING PREGNANCY.

BY

DADA BIDEMI ABIGAIL

NACON/ND/HND/SET 46/039.

PRESENTED

TO

NIGERIAN ARMY COLLEGE OF NURSING

YABA, LAGOS.

DEPARTMENT OF NURSING SCIENCES.

FEBRAURY, 2023.

I
 CASE STUDY OF MRS O.P WITH URINARY TRACT

INFECTION DURING PREGNANCY.

BY

DADA BIDEMI ABIGAIL

PRESENTED

TO

NIGERIAN ARMY COLLEGE OF NURSING YABA, LAGOS.

DEPARTMENT OF NURSING SCIENCES.

IN

PARTIAL FULFILMENT OF THE REQUIREMENT OF

NURSING AND MIDWIFERY COUNCIL OF NIGERIA FOR THE

AWARD OF REGISTERED NURSING (RN) CERTIFICATE.

FEBRUARY, 2023.

II
 CERTIFICATION

This is to certify that this care study was carried out by

NACON/ND/HND/SET 46/021, SN. Dada Bidemi A. under the

supervision of Seargent Bulus Amos.

NAME OF SUPERVISOR: SGT. BULUS AMOS.

SIGNATURE DATE

_________________ ___________________.

NAME OF COMMANDANT: COL J.O AWUTO

SIGNATURE DATE

______________________________ ______________________________.

III
 DEDICATION

This care study is dedicated to the Almighty God, for His mercy, kindness,

profound love, and his grace to achieve this work successfully. To the

development of nursing and nursing science as a whole.

IV
 ACKNOWLEDGEMENT

My gratitude goes to the Almighty God who is the author and finisher of

my faith, has bestowed upon me the strength, wisdom, knowledge and

might to complete this project. Also, to the Nigerian Navy for the privilege

given to study this distinguished course on scholarship.

My gratitude also goes to my project supervisor Sgt. Bulus Amos for his

immense contribution, guidance and direction at various stages of this write

up.

To my beloved Mother Mrs. Aina Awokoya who has always been a

bedrock for me, my mentor Mr. Okoronkwo Augustus C. for his

motivation and moral support throughout the course, also to my set

coordinator and entire students of set 46 and non-academic staff whose

name could not appear in the write up.

V
 TABLE OF CONTENT

Certification ________________________________________________________ III

Dedication __________________________________________________________ IV

Acknowledgement ___________________________________________________ V

Table Of Content_____________________________________________________ VI

Chapter One

1.1 Introduction _______________________________________________________ 1

1.2 Objectives Of Study ________________________________________________ 2

Chapter Two

LITERATURE REVIEW _______________________________________________ 3

2.0 Preamble _________________________________________________________ 3

2.1 Anatomy And Physiology Of The Urinary System ________________________ 5

2.2 Pathophysiology __________________________________________________ 13

2.3 Clinical Manifestation ______________________________________________ 13

2.4 Diagnostic Investigations ___________________________________________ 14

2.5 Management _____________________________________________________ 15

2.6 Differential diagnosis ______________________________________________ 19

2.7 Complications ____________________________________________________ 19

Chapter Three

3.1 Patient’s Bio-Data _________________________________________________ 21

3.2 Admission Of Patient And History Taking ______________________________ 21

3.3 History Taking ___________________________________________________ 22

3.4 Assessment Of Patient Using Gordon Brown’s Eleven Functional Pattern _____ 23

3.5 General Examination ______________________________________________ 24

3.6 Medical Management ______________________________________________ 25

VI
3.7 Comperative Signs And Symptoms ___________________________________ 26

3.8 Comparative Investigations And Results _______________________________ 26

3.9 Day To Day Nursing Management Of Patient ___________________________ 27

3.10 List Of Nursing Diagnosis _________________________________________ 30

3.11 Health Education _________________________________________________ 33

3.12 Discharge ______________________________________________________ 33

3.13 Follow Up Care Of Patient _________________________________________ 33

3.14 Drug Review Chart _______________________________________________ 34

3.15 Conlusion ______________________________________________________ 37

3.16 Recommendations ________________________________________________ 37

References __________________________________________________________ 38

Appendix 1 : Drug Course Chart

Appendix 2: Vitals Signs Chart.

Appendix 3: Fluid Intake And Output Chart.

VII
 CHAPTER ONE

1.1 INTRODUCTION

This is a case study of Mrs. O.P, a 28 year old lady admitted into the Gynecological

ward of 68, Nigerian Army Reference Hospital Yaba, on the 25th of November,

2022 with a diagnosis of Urinary Tract Infection (Urinary Tract Infection).

Patient was brought into the ward around 12:48pm by the Ward attendant from the

Ante-natal clinic. On admission, she was conscious, afebrile, and weak with the

following vital signs;

Temperature: 36.6oC, Pulse: 96b/m, Respiration: 22c/m, Blood pressure:

105/60mmhg, SPO2: 98%.

The urinary system is responsible for providing the route for drainage of urine

formed by the kidneys, and these should be fully functional because the damage

could easily affect other body systems.

Urinary tract infections are infections caused by pathogenic micro-organism in the

urinary tract. Urinary tract infections can be classified into:

⚫ Lower urinary tract infection: these include: bacterial cystitis, prostatitis, and

urethritis.

⚫ Upper urinary tract infections: these are much less common and include acute

and chronic pyelonephritis, interstitial nephritis, and renal nephritis.

⚫ Uncomplicated lower or upper urinary tract infections: these are community

acquired and are common in young women but not usually recurrent.

1
⚫ Complicated lower or upper urinary tract infections: usually occur in people

with urologic abnormalities or recent catheterization and are often acquired during

hospitalization.

Urinary Tract Infections are a common cause of serious infection and are frequently

encountered in pregnant women. Some of the factors that may predispose an

individual to for Urinary Tract Infection include pregnancy include low socio-

economic status, young age, and nulliparity. Pyelonephritis is the most common

serious medical condition seen in pregnancy and may present similarly and may

even result from inadequate treatment of urinary tract infections. Thus, it is critical

for providers to be able to distinguish normal versus abnormal findings of both the

urinary tract and kidneys, evaluate abnormalities, and treat disease. Fortunately,

urinary tract infections in pregnancy have a good prognosis and are usually easy to

treat and respond well to treatment.

1.2 OBJECTIVES OF STUDY

⚫ To identify the etiology of urinary tract infections pregnancy

⚫ To explain how to diagnose urinary tract infections in pregnant patients

⚫ To review strategies for improving care and outcomes in pregnant patients with

urinary tract infections.

⚫ To render efficient and maximum nursing care to patient in order to promote quick

recovery.

⚫ In partial fulfilment of nursing and midwifery Council of Nigeria requirement for

the award of a registered nurse certificate.

2
 CHAPTER TWO

LITERATURE REVIEW

2.0 PREAMBLE

The term pregnancy refers to events that occur from the time of fertilization

(conception) until the infant is born. During pregnancy, urinary tract changes

predispose women to infection. Ureteral dilation is seen due to compression of the

ureters from the gravid uterus. Hormonal effects of progesterone also may cause

smooth muscle relaxation leading to dilation and urinary stasis, and vesicoureteral

reflux increases. The organisms which cause Urinary Tract Infection in pregnancy

are the same uropathogens seen in non-pregnant individuals. As in non-pregnant

patients, these uropathogens have proteins found on the cell-surface which enhance

bacterial adhesion leading to increased virulence. Urinary catheterization,

frequently performed during labor, may introduce bacteria leading to Urinary Tract

Infection. In the postpartum period, changes in bladder sensitivity and bladder

overdistention may predispose to Urinary Tract Infection. (Nandy P. et al

“Characterization of bacterial strains isolated through microbial profiling of urine

samples”, 2017).

Pregnancy is a state of relative immunocompromise. This immunocompromise may

be another cause for the increased frequency of Urinary Tract Infections seen in

pregnancy. The most significant factor predisposing women to Urinary Tract

Infection in pregnancy is asymptomatic bacteriuria (ASB). ASB is defined as more

than 100,000 organisms/mL on a clean catch urinalysis obtained from an

asymptomatic patient. If asymptomatic bacteriuria is untreated in pregnancy, the

3
rate of subsequent Urinary Tract Infection is approximately 25%. Due to both to the

high rate and potential seriousness of pyelonephritis, it is recommended that all

pregnant women be screened for ASB at the first prenatal visit. This is most often

done with a clean catch urine culture. Treatment of ASB decreases the rate of

clinical infection to 3% to 4%. (Ncolle LE. Et. Al 2019 clinical practice guideline

for the management of Asymptomatic Bacteriuria).

The rate of asymptomatic bacteriuria in non-pregnant women is 5% to 6% which

compares similarly to estimated rates in pregnancy of 2% to 7%. ASB is seen more

frequently in parous women and women of low socioeconomic status. Women who

are carriers for sickle cell trait also have a higher incidence of ASB. (Nicolle LE.

Management of asymptomatic bacteriuria in pregnant women. Lancet Infect Dis

2015; 15:1252.)

Urinary Tract Infections are a common cause of serious infection in pregnant

women. In one study, 3.5% of antepartum admissions were due to Urinary Tract

Infection. Pyelonephritis is the most common cause of septic shock in pregnant

women. Risk factors for Urinary Tract Infections in pregnancy include low

socioeconomic status, young age, and nulliparity. As with ASB some patients may

be predisposed to infection and may report a history of having had ASB, cystitis or

pyelonephritis in the past. Pyelonephritis is more often right-sided however may be

bilateral in up to 25% of cases. (Bono MJ et al. “Urinary Tract Infection (Nursing).”

National Center for Biotechnology Information, U.S. National Library of Medicine,

https://pubmed.ncbi.nlm.nih.gov/33760460/.)

4
2.1 ANATOMY AND PHYSIOLOGY OF THE URINARY SYSTEM

The urinary systems include the kidneys, ureters, bladder, and urethra. Urine is

formed by the kidney and flows through the other structures to be eliminated from

the body.

Kidneys

The kidneys are a pair of bean-shaped, brownish-red structures located

retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of

the abdomen from the 12th thoracic vertebra to the third lumbar vertebra in the adult.

The average adult kidney weighs approximately 113 to 170g.

It is also approximately 10 to 12cm long, 6cm wide, and 2.5cm thick. The right

kidney is slightly lower than the left due to the location of the liver.

An adrenal gland lies on top of each kidney. The kidneys and adrenal glands are

independent in function, blood supply, and innervation.

Each kidney contains approximately 8 to 18 pyramids. The pyramids drain into

minor calyces, which drain into major calyces that open directly into the renal pelvis.

The renal pelvis is the beginning of the collecting system and is composed of

structures that are designed to collect and transport urine. Once the urine leaves the

renal pelvis, the composition or amount of urine does not change.

The cortex, which is approximately 1 cm wide, is located farthest from the center of

the kidney and around the outermost edges. It contains the nephrons (the functional

units of the kidney); in which urine formation occurs.

5
 FIG 1: THE DIAGRAM OF THE HUMAN KIDNEY.

Nephron.

The nephron is the functional unit of the kidney and is responsible for filtering waste

and excess fluids from the blood. It is estimated that there are approximately one

million nephrons in each kidney. Each nephron is made up of several components

including

⚫ The glomerulus: it is a mass of blood vessels that act as a filter for blood and it filters

out substances of small molecular masses from the blood.

⚫ Bowman's capsule: it is a sac like structure that surrounds the glomerulus and

collects the filtered fluid.

⚫ The Proximal tubule: this is a part of the nephron that allows for reabsorption and

secretion of substances.

⚫ The Loop of Henle

6
⚫ The Distal tubule

⚫ The Collecting duct: this is where all fluids after the process of urine formation,

collect and are ready to be moved to the ureters.

FIG 2: THE DIAGRAM OF THE NEPHRON

Blood supply to the kidneys

i. Arterial supply: Renal arteries that branch from abdominal aorta.

ii. Venous drainage: Renal veins.

Ureters

The urine formed in the nephrons flows into the renal pelvis and then into the ureters,

which are long fibromuscular tubes that connect each kidney to the bladder. These

narrow tubes, each 24 to 30 cm long, originate at the lower portion of the renal

pelvis and terminate in the trigone of the bladder wall. The left ureter is slightly

7
shorter than the right ureter. The lining of the ureters is made up of transitional cell

epithelium called urothelium. The urothelium prevents reabsorption of urine. The

movement of urine from each renal pelvis through the ureter into the bladder is

facilitated by peristaltic contraction of the smooth muscles in the ureter wall

Urinary Bladder

The urinary bladder is a muscular, hollow sac located just behind the pubic bone.

The capacity of the adult bladder is 400 to 500 mL. The bladder is characterized by

its central, hollow area, called the vesicle, which has two inlets (the ureters) and one

outlet (the urethra). The area surrounding the bladder neck is called the

ureterovesical junction. The angling of the ureterovesical junction is the primary

means of providing antegrade, or downward, movement of urine, also referred to as

efflux of urine. This angling prevents vesicoureteral reflux (retrograde, or backward,

movement of urine) from the bladder, up the ureter, toward the kidney.

The Urethra

The urethra transports urine from the bladder to the outside of the body for disposal.

The urethra is the only urologic organ that shows any significant anatomic

difference between males and females; all other urine transport structures are

identical.

The urethra in both males and females begins inferior and central to the two ureteral

openings forming the three points of a triangular-shaped area at the base of the

bladder called the trigone. The urethra tracks posterior and inferior to the pubic

symphysis. In both males and females, the proximal urethra is lined by transitional

epithelium, whereas the terminal portion is a nonkeratinized, stratified squamous

epithelium. In the male, pseudostratified columnar epithelium lines the urethra

8
 between these two cell types.

Voiding is regulated by an involuntary autonomic nervous system-controlled

internal urinary sphincter, consisting of smooth muscle and voluntary skeletal

muscle that forms the external urinary sphincter below it.

FEMALE URETHRA

The external urethral orifice is embedded in the anterior vaginal wall inferior to the

clitoris, superior to the vaginal opening (introitus), and medial to the labia minora.

Its short length, about 4 cm, is less of a barrier to fecal bacteria than the longer male

urethra and the best explanation for the greater incidence of Urinary Tract Infection

in women. Voluntary control of the external urethral sphincter is a function of the

pudendal nerve. It arises in the sacral region of the spinal cord, traveling via the S2–

S4 nerves of the sacral plexus.

2.1.1 THE PROCESSES OF URINE FORMATION

The three main processes involved in urine formation can be described as follows:

1. Glomerular Filtration: This is the process in which blood is filtered by the Bowman's

capsule of the nephrons within the kidney to form a filtrate, which contains waste

products, excess fluid, and electrolytes. Glomerular filtration is a passive process

driven by the hydrostatic pressure in the glomerulus.

2. Tubular Reabsorption: This is the process by which substances in the filtrate are

selectively reabsorbed into the bloodstream through the renal tubules. The renal

tubules are lined with specialized cells that perform reabsorption through various

transport mechanisms, including passive diffusion, facilitated diffusion, and active

transport.

9
3. Tubular Secretion: This is the process by which substances are secreted into the

filtrate by the renal tubules. This process is the opposite of reabsorption and helps

to further regulate the composition of the filtrate. Tubular secretion is often used to

remove waste products that cannot be filtered by the glomerulus or that are produced

in the renal tubules.

2.1.2 THE MICTURITION REFLEX AND BLADDER CONTROL

The micturition reflex, also known as the bladder reflex, is the process by which the

bladder contracts and releases urine. The micturition reflex is regulated by both the

voluntary and involuntary nervous systems. When the bladder is full and stretching,

sensory nerve fibers send signals to the spinal cord and brain, resulting in the feeling

of needing to urinate. If a person chooses to void their bladder, they use the

voluntary nervous system to initiate the micturition reflex and contract the bladder

muscles.

However, if a person chooses to delay urination, the involuntary nervous system

takes over and maintains bladder control by inhibiting the micturition reflex. This

allows the person to hold urine in their bladder for a period of time until they can

find a suitable place to void. Over time, if the bladder continues to fill and stretch,

the sensory nerve fibers will send stronger signals to the spinal cord and brain,

resulting in an increased urgency to void.

Bladder control can be influenced by several factors, including age, hormonal

changes, and certain medical conditions. For example, as people age, they may

experience a decline in bladder control, and women may experience changes in

bladder control during pregnancy or menopause. Certain medical conditions, such

10
 as urinary incontinence or over-active bladder, can also impact bladder control.

(Ross and Wilson Anatomy and physiology in Health and illness 12th edition. 2014)

2.1.3 FUNCTIONS OF THE URINARY SYSTEM

The urinary system has several key functions, including:

1. Waste and toxin elimination: The kidneys filter waste and toxic substances from the

blood, and these waste products are eliminated from the body as urine.

2. Fluid and electrolyte balance: The kidneys regulate fluid and electrolyte balance in

the body by filtering excess fluid and electrolytes and reabsorbing what is needed.

3. Blood pressure regulation: The kidneys play a role in regulating blood pressure by

secreting the hormone renin, which regulates the constriction and dilation of blood

vessels.

4. Acid-base balance: The kidneys regulate the acid-base balance in the body by

eliminating excess acid in the form of waste products and conserving bicarbonate,

which helps neutralize acid in the body.

5. Red blood cell production: The kidneys produce a hormone called erythropoietin,

which stimulates the production of red blood cells.

6. Vitamin D synthesis: The kidneys play a role in the synthesis of vitamin D, which

is important for bone health.

11
2.1.4 CHANGES IN THE URINARY TRACT DURING PREGNANCY

Pregnancy causes definite and marked changes in the urinary tract. They are:

1. Dilatation of the ureter and kidney pelvis usually more marked on the right side.

2. As the uterus grows larger and moves upward, the bladder is pushed forward and

upward.

3. The wall of the bladder becomes thickened, the blood vessels become enlarged,

and fluid collects in the tissues forming the wall of the bladder. The results are stasis

of blood in the blood vessels, and some mechanical inflammation of the bladder

wall.

4. There is a reduction in the ability of the kidney to reabsorb glucose.

The urethra which discharges urine from the bladder is stretched and distorted.

FIG 3: Anterior view of the Urinary organs of a female

12
2.2 PATHOPHYSIOLOGY

Organisms causing Urinary Tract Infection in pregnancy are the same uropathogens

which commonly cause Urinary Tract Infection in non-pregnant

patients. Escherichia coli is the most common organism isolated. An 18-year

retrospective analysis found E. coli to be the causative agent in 82.5% of cases of

pyelonephritis in pregnant patients. Other bacteria which may be seen include:

Klebsiella pneumoniae, Staphylococcus, Streptococcus, Proteus,

and Enterococcus species.

2.3 CLINICAL MANIFESTATION

Patients with asymptomatic bacteriuria have no symptoms; thus, it is important to

screen for the disease. These patients may have a history of frequent Urinary Tract

Infection or may have experienced ASB in a prior pregnancy.

Cystitis presents with the same symptoms seen in non-pregnant individuals.

Symptoms may include pain or burning with urination (dysuria), urinary frequency

or urinary urgency. Suprapubic pain and tenderness may be noted.

Likewise, patients with pyelonephritis exhibit symptoms seen in non-pregnant

patients with the same disease. Symptoms may include flank pain, fever, and chills.

Non-specific symptoms such as malaise, anorexia, nausea, and vomiting may be

reported thus the differential diagnosis on initial presentation is often broad.

Differential diagnosis includes acute intraabdominal processes such as appendicitis,

cholecystitis, and pancreatitis as well as pregnancy complications including

preterm labor and placental abruption. Patients may report contractions or

contractions may be seen with uterine monitoring. This uterine activity often is due

13
to smooth muscle irritability caused by infection. Patients should be assessed, and

if cervical dilation is not found, treatment is typically not needed for preterm labor.

Patients should be monitored closely however as preterm labor may develop.

Signs and symptoms of sepsis may be present. These include tachycardia and

hypotension. Such patients require prompt evaluation and interventions. (Hinkle JL,

et. al; Suddarth's textbook of Medical-Surgical Nursing. Wolters Kluwer; 2018.)

2.4 DIAGNOSTIC INVESTIGATIONS

A full physical examination should be performed with special attention to vital

signs and exam of the heart and lungs.

An abdominal examination may reveal tenderness, and costovertebral tenderness

is usually able to be elicited.

A genitourinary (GU) examination should be performed to assess for cervical

infection and assess cervical dilation on admission. Even when pregnancy

complications are not a concern initially, it is still reasonable to evaluate if

contractions or other abnormalities occur during hospitalization.

Urinalysis and clean catch urine culture: In the collection of urinary specimens

in pregnancy a few considerations are noteworthy. Patients who are well hydrated

may excrete dilute urine rendering some assessed parameters to be less accurate.

Hematuria may be seen as a result of contamination, particularly when specimens

are collected from laboring or postpartum patients. Due to reduced reabsorption of

protein, small amounts of protein may normally be excreted. Contamination, as may

occur with mucous discharge, may also contribute to the presence of proteinaceous

material in the urine of pregnant women.

14
Laboratory analysis should include complete blood count (CBC), electrolytes and

serum creatine.

Tailored studies should be included as appropriate to exclude other causes of patient

symptoms, for example, amylase and lipase if pancreatitis is being considered as a

diagnosis. If there is a concern for sepsis lactic acid and blood cultures should be

obtained. All cultures should be obtained as soon as possible and before starting

antibiotic therapy.

When the fetus is viable, fetal heart rate and contraction monitoring should occur.

Consideration should be given to obtaining cervical and GBS cultures on admission

if pregnancy-related complications develop. Infrequently, renal ultrasound may be

indicated to assess for a possible renal abscess.

2.5 MANAGEMENT

2.5.1 MEDICAL MANAGEMENT.

ASB and acute cystitis are treated with antibiotic therapy. Antibiotic choice can be

tailored based on organism sensitivities when available from urine culture results.

One-day antibiotic courses are not recommended in pregnancy, although 3-day

courses are effective. Antibiotics commonly used include: amoxicillin, ampicillin,

cephalosporins, nitrofurantoin, and trimethoprim sulfamethoxazole.

Fluoroquinolones are not recommended as a first-line treatment in pregnancy due

to conflicting studies regarding teratogenicity. Short courses are unlikely to be

harmful to the fetus, and thus, it is reasonable to use this class of drugs with resistant

or recurrent infections.

15
Recently evidence has developed suggesting a link between the use of sulfa

derivatives and nitrofurantoin and congenital disabilities when these medications

are prescribed in the first trimester. These studies have had limitations; however, it

is currently recommended to avoid the use of these medications in the first trimester

when alternatives are available because, the potential consequences of untreated

Urinary Tract Infection in pregnancy are significant, it is reasonable to use these

medications when needed as the benefit strongly outweighs the risk of use.

Additional Urinary Tract Infections exist with respect to these 2 classes of

antibiotics. Patients with G6P deficiency should not be prescribed sulfa derivatives

or nitrofurantoin as these medications can precipitate hemolysis. In the late third

trimester, trimethoprim-sulfamethoxazole should be avoided due to the potential

risk for development of kernicterus in the infant following delivery.

If Group B Streptococcus (GBS) is noted on urine culture, patients should receive

intravenous (IV) antibiotic therapy at the time of delivery in addition to indicated

treatment for ASB or Urinary Tract Infection. This is to prevent the development of

early-onset GBS sepsis which may occur in the infants of women who are colonized

with GBS.

Pyelonephritis in pregnancy is a serious condition usually requiring hospitalization.

Once an evaluation has been completed, treatment consists primarily of directed

antibiotic therapy and IV fluids to maintain adequate urine output. Fever should be

treated with a cooling blanket and acetaminophen as needed. Commonly, second

or third generation cephalosporins are used for initial treatment. Ampicillin and

gentamicin or other broad-spectrum antibiotics are alternatives. Patients should be

monitored closely for the development of worsening sepsis. (Ethan M.et.

16
 al "Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in

Women 2019).

2.5.2 NURSING MANAGEMENT URINARY TRACT INFECTION

UTILIZING THE NURSING PROCESS.

Assessment

⚫ Assess changes in urinary pattern such as frequency, urgency or hesitancy.

⚫ Assess the patient’s knowledge about antimicrobials and preventive healthcare

measures.

⚫ Assess the characteristics of the patient’s urine such as the color, odour,

concentration, volume, cloudiness.

History Taking

History of patient was taken including bio-data, patient post medical, surgical,

family and social history were taken from her directly

Nursing Diagnosis

Based on the patient’s examination, the following diagnoses were made:

1. Acute pain related to infection within the urinary tract evidenced by dysuria

2. Deficient knowledge related to lack of information regarding predisposing factors

and prevention of the disease evidenced by patient asking too many questions

3. Anxiety related to situational crises and unknown outcome of condition evidenced

by fear of unspecified consequences and multiple questions to the healthcare team.

17
 Planning

Based on the above diagnosis, the following are plan set aside for the patient’s care:

1. To relief pain.

2. To health educate the patient

3. To allay anxiety

Implementation

Patient was admitted into gynecological ward and the following measures were

employed:

⚫ To relief pain: antispasmodic agents to relieve bladder irritability, analgesics and

application of heat to relieve pain and spasm.

⚫ Patient was health educated; avoidance of urinary irritants such as coffee tea, colas,

and alcohol.

⚫ Patient was encouraged and reassured.

Evaluation

It involves reassessment of patient to confirm the extent of achievement in the

implementation phase. It is as follows:

1. Patient verbalized less pain after implementation of nursing actions.

2. Patient showed improved knowledge regarding her diagnosis.

3. Patient’s anxiety was allayed

4. Patient experiences no complication

18
 2.6 DIFFERENTIAL DIAGNOSIS

Differential diagnosis includes:

1. acute intra-abdominal disease such as:

⚫ Appendicitis

⚫ Pancreatitis

⚫ cholecystitis

2. pregnancy-related complications such as:

⚫ preterm labor

⚫ Chorioamnionitis

⚫ placental abruption.

2.7 COMPLICATIONS

Patients with pyelonephritis are at risk for several significant complications.

Sepsis may worsen resulting in hypotension, tachycardia, and decreased urine

output. ICU admission may be required.

Pulmonary complications are not uncommon, occurring in up to 10% of pregnant

patients undergoing treatment for pyelonephritis. This is due to endotoxin-mediated

alveolar damage and may manifest as pulmonary edema or acute respiratory distress

syndrome (ARDS). Urine output and oxygen status should be monitored closely,

and patients may require ICU admission for respiratory support.

Endotoxin release may lead to anemia, this typically resolves spontaneously

following treatment. This is the most common complication seen with

pyelonephritis occurring in up to 25% of patients.

19
Endotoxin release may also cause uterine contractions and patients should be

monitored for preterm labor; patients should be treated for preterm labor when

indicated.

A small number of patients may experience persistent infection. In

these cases, consideration should be given to urinary obstruction or renal abscess.

Antibiotic choice should be re-evaluated and culture results reviewed.

After 2 to 4 weeks following completion of treatment, urine culture should be

obtained to assure that reinfection has not occurred.

Suppressive antibiotic therapy, usually with nitrofurantoin once daily, is commonly

recommended especially in cases where patients have had prior Urinary Tract

Infection. This is typically continued throughout pregnancy and the early

postpartum period.

20
 CHAPTER THREE

3.1 PATIENT’S BIO-DATA

NAME: Mrs. O. P

AGE: 25 years

SEX: Female

MARITAL STATUS: Married

RELIGION: Christianity

ADDRESS: Block 64 room 5, Ojo Cantonment.

NEXT OF KIN: Ms. M. D

RELATIONSHIP: Sister

WARD: Gynecology ward

DATE OF ADMISSION: 25th Nov, 2022.

DIAGNOSIS: Urinary Tract Infection in Pregnancy

DATE OF DISCHARGE: 30th Nov, 2022.

3.2 ADMISSION OF PATIENT AND HISTORY TAKING

On 25th Nov 2022, Mrs. O.P was brought into the ward from ANC by Health

attendant. She was admitted on the basis of the following complains: dizziness,

abdominal pain and fever. Vitals at the time of admission were as follows;

⚫ Blood pressure- 105/60mmHg

⚫ Temperature- 36.6oC

⚫ Pulse- 96bpm

⚫ Respiration- 22c/m

21
⚫ SPO2-99%

Patient was introduced to the ward, shown her bed, the sluice room, bathroom, and

kitchen and where her luggage will be kept and patient's consent was sought to write

in her case. Patient and her relatives were informed about the visiting time of the

Hospital, and the time for breakfast, lunch and dinner respectively. The Hospital

standards were made known to the patient and her relative.

Patient was admitted into an unoccupied bed made ready for her, placed on her

prescribed drugs, investigations were also ordered as follows: PCV, Obstetrics USS,

FBC, MP, HCV, HBSAg, Genotype, Urinalysis.

3.3 HISTORY TAKING

Mrs. O.P is a primigravid (G1P0+0) who came into ANC with complains of

abdominal pain, dizziness, loss of appetite and fever. Last menstrual period (LMP)

was at 22/7/22, EGA is at 17weeks and her estimated delivery date (EDD) is

28/4/2023. She was seen by Dr. Eke who counseled and admitted her into the

gynecology ward.

I. PAST MEDICAL HISTORY

Nil medical history

II. PAST SURGICAL HISTORY

No record of past surgical history.

III. PATIENT SOCIAL HISTORY

Patient relates with her family well, does not smoke but takes alcohol.

IV. DRUG HISTORY

No history of chronic drug use, nil reaction to any drug but she is allergic to perfume.

V. FAMILY HISTORY

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 No history of any genetic disease.

VI. HISTORY OF PRESENT ILLNESS

Patient was in her usual state of health until about 24hrs ago when she started feeling

weak, feverish, anorexic, and also noticed to be having abdominal pains. She is

anicteric, acyanosed, not dehydrated, warm to touch, no loss of consciousness,

abdominal swelling or constipation/diarrhea, no spotting.

3.4 ASSESSMENT OF PATIENT USING GORDON BROWN’S ELEVEN

FUNCTIONAL PATTERN

1. HEALTH PERCEPTION- MANAGEMENT PATTERN

Patient values health and sees it as a top priority in her life, also adopts positive

health behavior and adheres to medical advice. She takes a walk every day in the

barracks.

2. NUTRITIONAL/METABOLIC PATTERN

Patient verbalized loss of appetite and nausea in relation to certain meals e.g. beans,

egusi soup and non-peppery meals.

3. ELIMINATION AND EXCHANGE

Patient eliminates well but has history of polyuria and occasional dysuria.

4. SLEEP AND REST PATTERN

Patient sleeps well and more since she got pregnant but complained that the frequent

urination now interrupts her sleep.

5. COGNITIVE/ PERCEPTUAL PATTERN

Patient can make use of all her senses and takes decisions for herself.

6. SELF PERCEPTION /SELF CONCEPT PATTERN:

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 Patient is hopeful and well rested since admission commenced. She is hopeful of

full recovery.

7. ROLE/RELATIONSHIP PATTERN

8. Patient relates well with her family, relatives, colleagues, health workers and co-

patients.

8. SEXUALITY/REPRODUCTIVE PATTERN

Patient is sexually active but yet to have her own child. This is her first pregnancy.

9. ACTIVITY/EXERCISE PATTERN

Patient is a very busy type due to the nature of her job.

10. COPING/ STRESS TOLERANCE PATTERN

Patient has positive coping mechanism, and tolerates stress well.

11. VALUE/BELIEF PATTERN

Patient believes in a supernatural being as she practices Christianity.

3.5 GENERAL EXAMINATION

Patient's condition was satisfactory head to toe; nil abnormality detected; vital signs

were within normal range as thus;

⚫ B.P: 105/60mmHg

⚫ Temperature- 36.6oC

⚫ Pulse- 96bpm

⚫ Respiration- 22c/m

Physical examination

These includes; inspection, palpation, auscultation, and percussion.

24
 (i) INSPECTION: The patient was observed in a standing position and in supine

position; Cervical os is closed, nil discharge, nil abnormal findings from head to toe.

Vital signs showed no abnormal findings.

(ii) PALPATION: On palpation of the abdomen, tenderness was exhibited on the

suprapubic region.

(iii) AUSCULTATION: lung sound and heart sound are normal. Bowel sound is

also normal

(iv) PERCUSSION: There was pain in the abdominal region.

INVESTIGATIONS

⚫ Full Blood Count

⚫ Urinalysis

⚫ Obstetrics Scan.

3.6 MEDICAL MANAGEMENT

Patient was placed on strict bed rest and on several medications (Pharmacological

management)

⚫ IVF Normal saline 1000mlsthen 500mls 6hrly

⚫ IV PCM 600mg 8hrly

⚫ Promethazine tab 25mg b.d

⚫ Tab fesolate 200mg b.d

⚫ Tab Vit Bco i. b.d

⚫ Tab folic acid 5mg dly

⚫ Tab cefuroxime 500mg b.d

⚫ Tab Vit C 1g b.d

25
 3.7 COMPERATIVE SIGNS AND SYMPTOMS

SS/N CLINICAL CLINICAL MANIFESTATION AS

MANIFESTATION AS IN PRESENTED BY THE PATIENT.

LITERATURE

1. Pain. Present

2. Tachycardia Absent

3. Vomiting Present

4. Malaise Present

5. Tenderness Present

6. Fever Absent

7. Discharge Absent

8. Dysuria Present

9. Frequency Absent

3.8 COMPARATIVE INVESTIGATIONS AND RESULTS

S/N GENERAL PATIENT’S NORMAL REMARKS

INVESTIGATIONS RESULTS RANGE

1. HBsAg Non-reactive

2. HCV Non-reactive

26
 3. WBC 8.3 X 109/L 4-11 X 109/L NORMAL

4. PLATELET COUNT 193 X 109/L 100-400 X NORMAL

109/L

5. LYMPHOCYTES 24% (2.0-45%) NORMAL

COUNT

6. EOSINOPHILS 07% (2-8%) NORMAL

7. NEUTROPHILS 69% (4.0-72) % NORMAL

8. PVC 28% 36-50% LOW

9. Hb Genotype AA

10. Hb 94g/L 120-160g/L LOW

11. HAEMATOCRIT 0.28L/L 0.36-0.45L/L LOW

3.9 DAY TO DAY NURSING MANAGEMENT OF PATIENT

DAY 1 (25/11/2022)

Patient was admitted into the ward, introduced to other patients and ward facilities,

patient was placed on a well-made bed and was made comfortable. Patient was

immediately placed on prescribed drugs. Patient’s vital signs were checked and

recorded as follows:

⚫ Blood pressure- 105/60mmHg

⚫ Temperature- 36.6oC

⚫ Pulse- 96bpm

⚫ Respiration- 22c/m

⚫ SPO2-99%.

27
 DAY 2 (26/11/2022).

Patient was reviewed by the medical team, several laboratory investigations were

requested for; Ultrasound scan, Full Blood Count, MP, PCV, HBsAg, HCV,

Urinalysis and Genotype; their respective sample specimen were taken and sent to

the lab. She was placed on IV artesunate which was commenced. Patient was made

comfortable and vital signs checked and recorded as follows:

⚫ Temperature: 36.5°c

⚫ Pulse: 90b/m

⚫ Blood pressure: 110/66mmHg

⚫ Respiration: 20c/m

⚫ Spo2: 99%

DAY 3 (27/11/2022).

Patient had three episodes of vomiting the previous night and 25mg of promethazine

was given, she was seen by Doctor Okechukwu. She also had her last dose of IV

artesunate.

Laboratory investigation results were reviewed. MP came out negative. PCV result

came out as 28%. She is to continue her antibiotic regimen and was placed on

hematinic.

⚫ Temperature: 36.7°c

⚫ Pulse: 78b/m

⚫ Respiration: 20c/m

⚫ Blood pressure: 100/65mmHg

⚫ Spo2: 97%.

28
 DAY 4 (28/11/2022).

Patient was seen by Dr. Okorafor; results of hematologic tests and obstetrics USS

were reviewed. Patient was non-reactive to HBsAg and HCL. Obstetrics USS

reviewed that the placenta is anterior, liquor volume is adequate, the cervical os is

closed, no gross fetal anomaly noted. PCV result came out as 30%. She is to

continue her current management.

⚫ Temperature: 36.5°c

⚫ Pulse: 70b/m

⚫ Respiration: 20c/m

⚫ Blood pressure: 110/80mmHg

⚫ Spo2: 98%.

DAY 5 (29/11/2022).

Patient was seen by the medical team, Patient in no obvious painful distress. Still

follow current management, patient was made comfortable, she had no complaints.

She was to be discharge but she wanted to remain on admission for that day. Vital

signs checked and documented:

⚫ Temperature: 36.4°c

⚫ Pulse: 88b/m

⚫ Blood pressure: 110/80mmHg

⚫ Respiration: 20c/m

⚫ Spo2: 98%

DAY 6 (30/11/2022).

Patient was seen by Dr. Okorafor, Patient in no obvious painful distress. Still follow

current management, patient was made comfortable, she had no complaints, she was

29
 discharged, take home drugs were given and explained to her, health education was

done, her vitals were also checked on discharge:

⚫ Temperature: 36.4°c

⚫ Pulse: 88b/m

⚫ Blood pressure: 110/80mmHg

⚫ Respiration: 20c/m

⚫ Spo2: 98%

3.10 LIST OF NURSING DIAGNOSIS

⚫ Acute pain related to infection within the urinary tract evidenced by dysuria.

⚫ Hyperthermia related to infectious process evidenced by increase body temperature

⚫ Deficient knowledge related to lack of information regarding disposing factors and

prevention of the disease evidenced by patient asking too many questions.

30
NURSING CARE PLAN OF MISS MRS O.P WITH UTI IN PREGNANCY

S/N Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation

1. Acute pain related Patient will be i. Assess level of pain using the i. To know the level of Patient was
to infection within relieved of pain 1-10 pain rating scale pain. relieved of
the urinary tract within 48 hours of ii. Assess for signs and ii. To allow timely pain after
evidenced by nursing symptoms of urinary tract healthcare intervention. about 24
dysuria. intervention. infection iii. To relieve pain and hours of
. iii. Apply a heating pad to the spasm. nursing
suprapubic area or lower back. iv. To block pain signals to intervention.
iv. Administer prescribed the brain and reduce bladder
analgesics or antispasmodic e.g. irritability respectively.
paracetamol, phenazopyridine.
2. Hyperthermia Patient will 1. Assess for signs of increased i. To determine the severity Patient’s core
related to infectious maintain core body temperature. of patient’s condition temperature
process evidenced temperature within 2. Provide a tepid sponge bath. ii. To reduce fever returned to
by increase body normal range after 3. Encourage adequate fluid iii. To prevent dehydration normal range
temperature about 30-45 intake precipitated by increase in after about 35
minutes of nursing 4. Administer prescribed temperature. minutes of
intervention antipyretics e.g. paracetamol. iv. To lower body nursing
temperature. intervention.

31
3. Deficient Patient will i. Health educate the patient. i. To make the patient know Patient
knowledge related verbalize ii. Teach patient about hygiene more about the illness. verbalized
to lack of knowledge of iii. Encourage frequent bladder ii. To prevent aggravation proper
information causes and emptying of condition and also to understanding
regarding disposing treatment of UTI, iv. Advice patient to avoid tight- promote quick recovery. of diagnosis
factors and controls risk fitting undergarments made of iii. To prevent bladder and
prevention of the factors and non-breathing materials. distention. treatment,
disease evidenced complete medical iv. These fabrics can preventive
by patient asking treatment with 48 accumulate moisture and practices
too many hours of nursing provide an environment for within 36
questions. intervention. bacteria growth. hours of
nursing
intervention.

32
 3.11 HEALTH EDUCATION

Patient was educated on the need to pay attention to his health; adhere to medical

advice, ensure adequate nutrition, observe both personal and environmental hygiene,

and report to hospital if any abnormality is noticed.

3.12 DISCHARGE

Patient was seen by Dr Okorafor, calm on bed, nil complains, patient’s vital signs

were within normal range and there was nil fresh complaint.

⚫ Tab cefuroxime 500mg b.d

⚫ Tab fesolate 400mg b.d

⚫ Tab folic acid ii b.d

⚫ Tab Vit C. 1g b.d

⚫ Tab Vit Bco ii b.d

⚫ To continue routine ANC medications

were prescribed and patient was discharged home in company of her husband. She

is to come for her routine ante natal care visits.

3.13 FOLLOW UP CARE OF PATIENT

While patient was at home, I called thrice to know how well she is coping, until she

came back for antenatal clinic, patient was much better without any complaint.

Patient was advised to eat adequate diet, ensure proper hygiene, ensure proper

hydration.

33
3.14 DRUG REVIEW CHART

S/N DRUGS DOSAGE ROUTE MODE OF ACTION SIDE EFFECTS NURSING

RESPONSIBILITIES
1. Cefuroxime 500mg b. Oral It belongs to a group of 1. Bloody or tarry 1. observe for allergies
d antibiotics called stool 2. Inform patient to use
cephalosporin. It works by 2. Decrease urinary any antacids 1hour before
stopping the growth of output using medication
bacteria. 3. Diarrhea
4. Sores, ulcer or
white spots in the
mouth.
2. Fesolate 400mg b.d Oral It belongs to the group of 1. Black stools 1. Advice patient that the drug
drugs called haematinics and 2. Allergic reactions is best taken on an empty
is used to treat and prevent 3. Liver damage stomach
iron deficiency anemia as it 4. Constipation 2. Advice patient to
helps the body produce 5. Loss of appetite discontinue medication and
healthy red blood cells report if there are signs of
haematuria.

34
 3. Advice patient not to take
drug with tea, egg, soybean or
any dairy products
3. folic acid Ii b.d Orally It is the synthetic version of 1. Anorexia 1. Advice patient to avoid
vitamin B9. It helps the body 2. Bloating alcohol
make healthy red blood cells. 3. Nausea 2. Advice patient not to take 2
4. Blisters doses to make up for a
forgotten dose.
3. Avoid taking medication
within 2 hours before or after
taking antacids
4. Paracetamol 900mg Orally It belongs to a class of drug Rashes, blood i. Teach patient symptoms of
8hrly called analgesic and disorders etc. overdose namely nausea,
antipyretic. It helps to relieve vomiting, abdominal pain etc.
pain. ii. Advise patient to avoid the
use in high fever.
Advise patient to avoid
prolonged use or excessive
consumption of the drug can
cause liver damage.

35
5. Tab Vit C. 1g b. d Orally It is an essential vitamin that 1. Nausea 1. Avoid alcohol and smoking
helps in boosting the immune 2. Stomach cramps 2. Avoid overdose
system. 3. Heartburn
4. Diarrhea
6. Tab Vit Bco I daily Orally This is a group of B vitamins 1. loss of feeling in 1. Medication can be used
that play a role in body the arms and legs before or after meal
functions including 2. Nausea and 2. Do not take medication with
cardiovascular and cell health vomiting alcohol or carbonated drinks.
3. Light sensitivity
4. Painful skin
lesions
5. Liver damage
6. Nervous system
damage

36
 3.15 CONLUSION

Patient; Mrs. O.P, a 28 year old lady admitted into the Gynecological ward of 68,

Nigerian Army Reference Hospital Yaba, on the 25th of November, 2022 with a

diagnosis of Urinary Tract Infection (UTI). Patient was brought into the ward

around 12:48pm by the Ward attendant from the Ante-natal clinic. The following

medical investigations were carried out; Ultrasound scan, Full Blood Count, MP,

PCV, HBsAg, HCV, Urinalysis and Genotype. Effective day to day management of

patient were carried out and medical care was effectively administered to patient,

prescribed medications were effectively and adequately administered to patient.

The Successful management of this patient came as a result of the collaboration of

all health workers and the entire management of 68 Nigerian Army reference

hospital Yaba at Large.

3.16 RECOMMENDATIONS

1. There should be a public enlightenment/ awareness on the predisposing factors,

causes, signs and symptoms, pathophysiology, complications of UTI.

2. There should be routine assessment of pregnant women’ s knowledge regarding the

prevention of UTI.

3. Pregnant women should be encouraged to visit the hospital once they notice any

change in their health.

37
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health and illness. Churchill Livingstone. Gazmararian JA, Petersen R, Jamieson.

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textbook of Medical-Surgical Nursing. Wolters Kluwer.

3. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management

of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of

America. Clin Infect Dis 2019; 68: e83.

4. DJ, Schild L, Adams MM, Deshpande AD, Franks AL. Hospitalizations during

pregnancy among managed care enrollees. Obstet Gynecol. 2020 Jul;100(1):94-100.

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