Arellano, Aigina Lucelle H.

BSN-2

August 15, 2011

CASE STUDY URINARY TRACT INFECTION (UTI)

INTRODUCTION: The urinary tract is comprised of the kidneys; ureters, bladder, and urethra. A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract. However, this is the broad definition of urinary tract infections; many authors prefer to use more specific terms that localize the urinary tract infection to the major structural segment involved such as urethritis (urethral infection),cystitis (bladder infection), ureter infection, and pyelonephritis (kidney infection). Other structures that eventually connect to or share close anatomic proximity to the urinary tract (for example, prostate, epididymis, and vagina) is sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. Technically, they are not UTIs and will be only briefly mentioned in this article. UTIs are common, more common in women than men, leading to approximately 8.3 million doctor visits per year. Although some infections go unnoticed, UTIs can cause problems that range from dysuria (pain and/or burning when urinating) to organ damage and even death. The kidneys are the active organs that, during their average production of about 1.5 quarts of urine per day, function to help keep electrolytes and fluids (for example, potassium, sodium, water) in balance, assist removal of waste products (urea), and produce a hormone that aids to form red blood cells. If kidneys are injured or destroyed by infection, these vital functions can be damaged or lost. While some investigators state that UTIs are not transmitted from person to person, other investigators dispute this and say UTIs may be contagious and recommend that sex partners avoid relations until the UTI has cleared. There is no dispute about UTIs caused by sexually transmitted disease (STD) organisms; these infections (gonorrhea, chlamydia) are easily transmitted between sex partners and are very contagious. What causes a UTI?

The most common causes of UTI infections (about 80%) are Escherichia coli bacterial strains that usually inhabit the colon. However, many other bacteria can occasionally cause an infection (for example, Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcus, Mycoplasma, Chlamydia, Serratia and Neisseria spp) but are far less frequent causes than E. coli. In addition, fungi (Candida and Cryptococcus spp) and some parasites (Trichomonas, Schistosoma) also may cause UTIs; Schistosoma causes other problems, with bladder infections as only a part of its complicated infectious process.

What are UTI risk factors? People more susceptible to UTI s:

y y y y y y y y y y y

Diabetics because of changes in the immune system Infants who are born with abnormalities of the urinary tract Women who use a diaphragm Women whose partners use a condom with spermicidal foam A person who has already had a UTI Pregnant women Post-menopausal women Women on birth control pills Women with lowered immunity Women with prolapsed urethra or bladder Women with obstructions in the urinary tract

There are many risk factors for UTIs. In general, any interruption or impedance of the usual flow of urine (about 50 cc per hour in normal adults) is a risk factor for a UTI. For example, kidney stones, urethral strictures, enlarged prostate, or any anatomical abnormalities in the urinary tract increases infection risk. This is due in part to the flushing or wash-out effect of flowing urine; in effect the pathogens have to "go against flow" because the majority of pathogens enter through the urethra and have to go retrograde (against a barrier, urine flow) to reach the bladder, ureters, and eventually the kidneys. Many investigators suggest that women are far more susceptible than men to UTIs because their urethra is short and its exit (or entry for pathogens) is close to the anus and vagina, which can be sources for pathogens. People who require catheters have an increased risk (about 30% of patients with indwelling catheters get UTIs) as the catheter has none of the protective immune systems to eliminate bacteria and offers a direct connection to the bladder. There are reports that suggest that women who use a diaphragm or who have partners that use condoms with spermicidal foam are at increased risk for UTIs. In addition, females who become sexually active seem to have a higher risk of UTI; some investigators term these UTIs as "honeymoon cystitis." Men over 60 have a higher risk for UTIs because many men at or above that age develop enlarged prostates that may cause slow and incomplete bladder emptying. Occasionally, people with bacteremia (bacteria in the bloodstream) have the infecting bacteria lodge in the kidney; this is termed hematogenous spread. Similarly, people with infected areas that are connected to the urinary tract (for example, prostate, epididymis, or fistulas) are more likely to get a UTI. Additionally, patients who undergo urologic surgery also have and increased risk of UTIs. Pregnancy does not apparently increase the risk of UTIs according to some clinicians; others think there is an increased risk between weeks six through 26 of the pregnancy. However, most agree that if UTIs occur in pregnancy, the risk of the UTI progressing in seriousness to pyelonephritis is increased according to several investigators. In addition, their baby may be premature and have a low birth weight. Patients with chronic diseases such as diabetics or those who are immunosuppressed (HIV or cancer patients) also are at higher risk for UTIs.

What are UTI symptoms and signs in women, men, and children? The UTI symptoms and signs may vary according to age, sex, and location of the infection in the tract. Some individuals will have no symptoms or mild symptoms and may clear the infection in about two to five days. Many people will not spontaneously clear the infection; some of the most frequent signs and symptoms experienced by most patients is a frequent urge to urinate, accompanied by pain or burning on urination. The urine often appears cloudy and occasionally reddish if blood is present. The urine may develop an unpleasant odor. Women often have lower abdominal discomfort or feel bloated and experience sensations like their bladder is full. Women may also complain of a vaginal discharge, especially if their urethra is infected, or if they have an STD. Although men may complain of dysuria, frequency, and urgency, other symptoms may include rectal, testicular, penile, or abdominal pain. Men with a urethral infection, especially if it is caused by an STD may have a pus-like drip or discharge from their penis. Toddlers and children with UTIs often show blood in the urine, abdominal pain, fever, and vomiting along with pain and urgency with urination. Symptoms and signs of a UTI in the very young and the elderly are not as diagnostically helpful as they are for other patients. Newborns and infants may develop fever or hypothermia, poor feeding, jaundice, vomiting, and diarrhea. Unfortunately, the elderly often have mild symptoms or no symptoms of a UTI until they become weak, lethargic, or confused. Symptoms depend on age of person and where the UTI is located. Symptoms of urethritis often include: y Burning sensation at the start of urination Symptoms of cystitis often include: y Burning sensation in the middle of urination y Fever y Lower abdominal pain y Funny smell, color, or appearance (cloudy, dark, blood tinged) of urine Symptoms of Pyelonephritis often include: y Pain in back, flanks, or abdomen y Fever y Nausea y Vomiting Other symptoms of UTI s: y Uncomfortable pressure above pubic bone y Fullness in rectum (in men only) y Small amount of urine, despite urge to urinate y Irritability (in children only) y Abnormal eating (in children only)

Nursing Management 1. Assess pain, noting location, intensity (scale of 0 10), duration. Rationale: Provides information to aid in determining choice or effectiveness of interventions. 2. Encourage increased fluid intake. Rationale: Increased hydration flushes bacteria and toxins. 3. Investigate report of bladder fullness. Rationale: Urinary retention may develop, causing tissue distention (bladder or kidney), and potentiates risk for further infection. 4. Observe for changes in mental status, behavior or level of consciousness. Rationale: Accumulation of uremic waste and electrolyte imbalances may be toxic to the CNS. 5. Provide comfort measure like back rub, helping patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercises. Rationale: Promotes relaxation, refocuses attention, and may enhance coping abilities. 6. Encourage use of sitz baths, warm soaks to the perineum. Rationale: Promotes muscle relaxation 7. Administer antibacterial as prescribed. Rationale: Reduces bacteria present in urinary tract and those introduced by drainage system.

CASE STUDY FRACTURES

Introduction to fracture Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and bone marrow is the production center for blood products. Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood. What causes a fracture? When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been damaged and the bone structure fails and a fracture occurs. Broken bones hurt for a variety of reasons including:
y y y

The nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised. Broken bones bleed, and the blood and associated swelling (edema) causes pain. Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed. Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces or trauma applied to the bone may determine what type of injury that occurs. Some fractures occur without any obvious trauma due to osteoporosis, the loss of calcium in bone (for example a compression fracture of the vertebrae of the back). Descriptions of fractures can be confusing. They are based on:
y y y y

Where in the bone the break has occurred How the bone fragments are aligned Whether any complications exist Whether the skin is intact

The first step in describing a fracture is to decide if it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries often need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Compound fracture was the previous term used to describe an open fracture. Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces? A greenstick fracture describes the situation when the bone partially breaks. This often occurs in infants and children where the bone hasn't completely calcified and has the potential to bend instead of breaking completely through. It is similar to trying to break off a young branch or shoot from a tree (a green stick). Other fracture terms include torus or buckle fracture, again when only part of a bone breaks, but this may occur in adults as well. Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their normal alignment.\

What is the treatment of a fracture? Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders or paramedics may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury. Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial splint does not go completely around the limb. After a few days, the splint is removed and replaced by a circumferential cast. Circumferential casting does not occur initially because fractures swell (edema). This swelling could cause a buildup of pressure under the cast, yielding increased pain and the potential for damage to the tissues under the cast. However, if the fracture required reduction (putting the bones back into alignment) there might be a need for circumferential cast to keep the ones in place. Surgery Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk for moving out of place once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an

operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery. Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time.

Nursing Management 1. Provide emergency management when situation warrants, for a new fracture.
y y y y y y y y y

Assess the five Ps . Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps . Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services.

2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications. 5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications.

y y

Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage. o Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. o Treatment entails pressure relief, which sometimes require performing a fasciotomy.

8. Prevent infection, including osteomyelitits, by using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.