Question

PN 200 Fundamentals of Nursing II CASE STUDY: URINARY TRACT INFECTION You are working in an extended care fa for a week stay while she goes on vacat history of dysuria, back pa king in an extended care facility when Maria Zippo's daughter brings her mother ay while she goes on vacation. Mrs. Zippo is a 69 year-old widow with a day of dysuria, back pain, incontinency, severe mental confusion, and loose stools. Her physician had recently discontinued her hormone replacement therapy one (1) month ago. Her most current vital signs are 118/60, 88, 18, 99.4 F. The medical director ordered several lab tests on admission. The results were as follows: WBC 11,000 CMP all values were within normal limits Post-voiding catheterization yielded 100 mL and urinalysis showed: WBC +100 under HPF (high power field) RBC3-6 Bacteria - rare Urinary culture and sensitivity results are as follows: E.coli > 100,000 colonies: sensitive to ciprofloxacin, trimethoprim- sulfamethoxazole, and nitrofurantoin. #1. What role does hormone replacement therapy play in the prevention of UTI's? 2. Explain the pathophysiology of the symptoms the patient displayed. #3. Which of the above laboratory values are abnormal; what are the normal values? # 4. What is the significance of the post-voiding catheterization? What is the normal amount of urine in the bladder to be expected? The medical director makes rounds and writes the order to start an IV of D/5 0.9%NS at 75 mL/hr. and insert a Foley retention catheter to straight drainage. Because Mrs. Zippo is unable to take oral medications, the physician orders ciprofloxacin 200mg twice daily IVPB. # 5. Is the type of fluid and rate appropriate for Mrs. Zippo and condition? Explain your rationale. #6. What type of adverse effects would you look for in a patient receiving IV ciprofloxacin?

Answer 1

Urinary tract infection is on of the most common type of infections seen in females. E.coli is the commonest causative organism of this infection. Based on the symptoms, UTI can be classified into lower urinary tract infection and upper urinary tract infection.The lower urinary tract infection or acute pyelonehritis is complicated as it shows symptoms of kidney damage.

1. The women after menopause has low estrogen levels which leads to urinary tract atrophy, This results in weakening of bladder and urethra and leads to lack of control on urination as well as increase in post residual urine volume. These makes urinary tract vulnerable to infection. Reduced estrogen level also decrease the normal flora of female genitalia which is the vaginal lactobacilli. This cause a decrease in the e vaginal pH and helps the colonization of the foreign bacteria in the genitalia and gradually leads to genitourinary infection. During hormone replacement therapy, the body will receive adequate amount of estrogen which helps to prevent Urinary tract infection.

2.The pathopysiogy of Urinary tract infection

i) The bacteria enter in the periurethral area in favorable condition and ascends through the urethra towards the bladder.

ii) The bacteria penetrate through the epithelial wall of the bladder and replicate inside the bladder.

iii) The bacteria ascends to the ureter towards the kidneys, bacterial toxins start to decrease the urine flow through ureter.

iv) The bacteria enter into kidneys causing inflammation of renal parenchyma which is called as pyelonephritis. As the inflammatory process continuous, the bacteria obstruct and damage the renal tubule causing acute kidney injury and further progress the infection into blood stream.

The patient has symptoms like dysuria ( difficulty in urination) , back pain, incontinence , severe mental confusion, and loose stools. The dysuria is due to inflammation of bladder wall which cause difficulty in contraction of bladder muscles. Back pain result from kidney injury and renal tube damage due to inflammation and edema.Incontinence is one of the non classic sign in older patients with UTI due to reduced bladder capacity caused by inflammation and edema. Severe mental confusion is one of the serious complication seen in older people affected with UTI. The bacteria enter into the blood may pass through the blood brain barrier and can cause confusion and cognitive disabilities. Loose stools or constipation are usually associated with UTI.

3.The WBC count in urine is 100+ HPF which is very high, the normal value is 0 - 5 HPF.

The RBC count is 3 - 6 which is high, The normal value is 4 or less HPF

The urine culture and sensitivity shows E.coli > 100,000 colonies, which is a sign of Urinary tract infection.

4. The post voiding catheterization is the introduction of catheter in sterile manner to empty the bladder after the patient has passed the urine. It helps to know the residual amount of urine and helps to collect urine sample for analysis. The importance of post residual urine volume measurement is, if it measures more than the normal amount, it shows the chance of acquiring urinary tract infection. The normal post void residual volume in young people is $\small \leq$ 50 mL and in older people more than 60 years is 50 - 100 mL.