Question

Patient Profile
L.M. is an 81-year-old female who lives in a nursing home. She had a stroke 2 years ago and has residual right-sided weakness. She also has gastroesophageal reflux disease, hypertension, and stress incontinence. She currently takes the following medications:
• Omeprazole 20 mg PO daily before breakfast
• Captopril 50 mg PO BID
• Furesomide 20 mg PO daily

Today she tells the nursing assistant that she has a lot of pain when she urinates. The charge nurse completes a physical exam and notifies the provider of the exam findings and patient’s painful urination. A urinalysis is ordered.

Subjective Data
• Pain with urination began 2 days ago
• States she usually doesn’t drink much because of the stress incontinence and not wanting to have “accidents,” and now she is drinking even less because doesn’t want to have to urinate due to the pain and burning
• Wearing feminine hygiene pads she had in her closet since the painful urination started because her stress incontinence “is worse”

Objective Data
Physical Examination
• Temperature 99.7° F, pulse 78, respirations 18, blood pressure 162/80
• Left flank tenderness
Diagnostic Studies
• Urinalysis
• Color: Dark, smoky color
• Odor: Foul smelling
• Protein: Trace
• Glucose: None
• Ketones: None
• Bilirubin: None
• Specific gravity: 1.034
• pH: 8.2
• RBCs: 8/hpf
• WBCs: 12/hpf
• Casts: Present

Discussion Questions
1. Based on L.M.’s presentation, what do you suspect is occurring and what assessment data led you to this conclusion?


2. You need to obtain a clean-catch urine sample from L.M. to send for urinalysis. To collect this specimen, what instructions do you give L.M.?


3. Describe how to assess for flank tenderness. What is the significance of L.M.’s left flank tenderness?

4. What are L.M.’s risk factors for developing a urinary tract infection?

5. What diagnostic test would be needed to determine the best medication to treat L.M.’s urinary tract infection?

6. What are some important measures to teach L.M. to prevent recurrence of a urinary tract infection (UTI)?

Answer 1

1. I suspect urinary tract infection ( any part of urinary system- kidney , bladder, urethra)

Reason: slight increase in body temperature, dark,smoky coloured foul smelling urine, left flank pain , slight alkaline urine may indicate infection.

2. Instructions to collect clear catch urine sample :

• Wash the area between the labia using sterile swipes.
• Sit on the toilet with legs spread apart. Use two fingers to spread open labia.
• Use the first wipe to clean the inner folds of the labia. Wipe from the front to the back.
• Use a second wipe to clean over the opening where urine comes out (urethra), just above the opening of the vagina.

• To collect the urine sample:

• Keeping your labia spread open, urinate a small amount into the toilet bowl, then stop the flow of urine.
• Hold the urine cup a few inches (or centimeters) from the urethra and urinate until the cup is about half full.
• You may finish urinating into the toilet bowl.

3.Asses flank tenderness by :

(Flank is the region between below the ribs and above the pelvic region)

• the location of pain
• when the pain began
• what the pain feels like
• how often pain comes
• how long pain lasts
• other associated symptoms
• other diagnostic tests include :
  • abdominal CT
  • cystoscopy
  • urinalysis
  • urine culture

significance of flank tenderness:

It may indicate

• kidney infection
• kidney stones
• dehydration
• bladder infection
• pancreatitis
• appendicitis
• inflammatory bowel disease
• abdominal aortic aneurysm

4. Risk factors for developing urinary tract infection:

• Old people are less immune.
• conditions like incontinence
• having urinary tract infection already
• they may be exposed to different bacteria in the hospital or care facility

5. Best diagnostic test would be culture the urine sample and give antibiotics to treat the patient, do cystoscopy.

6. Prevent recurrence of UTI :

• Have to drink lots of water
• Should keep genital area clean.
• If adult diapers are used, it should be changed regularly.
• always clean / wipe the genital area from front to back
• Not using douches or other feminine hygiene products
• should not drink fluids like alcohol or caffeine as it may irritate the bladder more.