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INTRODUCTION

Urinary tract infections (UTIs) are one of the most common serious infections
of early childhood. Babies can suffer from UTI's just like adults do, and often the only
clear symptom is that your child runs a fever. Urinary tract infections are caused by
bacteria that builds up in the urethra. While oftentimes adults feel the discomfort of
having to urinate frequently, babies may only show signs of this infection through
fever.
According to the American Academy of Pediatrics the most common
symptom associated with UTI's in babies is fever. If you are aware of what to look
for, however, you may be able to distinguish a few of the following symptoms, also.

Check the odor of your baby's urine. If it has a bitter or foul smell, that may indicate a
UTI.
 If you notice any blood in your baby's diaper, this probably indicates a UTI.
 If your baby cries for no apparent reason and may be running a fever, she
could have developed a urinary tract infection.
 If she is has a poor appetite and/or is vomiting, she may have a urinary tract
infection.
 If you suspect that your baby has an infection, contact your doctor.

While you may not be able to completely eliminate the risk of your baby
contracting a UTI, you can help lessen his chances by wiping him from the front to
the back when you change his diapers. This is especially true when changing baby
girls. Still, even with proper care, your baby could contract a UTI. With help from
your doctor and lots of extra TLC from you, however, your baby should bounce back
in no time!

NURSING HEALTH HISTORY

A. Biographic Data:

Name: Baby Sam


Address: Calamba,Laguna
Age: 3 mo.
Sex: Female
Nationality: Filipino
Religion: Roman Catholic

Health care Financing and Usual Source of Medical care: Phil.Health and maxicare
B. Chief Complaint or reason for visit

(LBM)
“Malambat ang dumi ng baby ko at madalas talagang dumumi”as verbalized by the
pt.mother

C. Hx.of present illness

1 week prior to admission pt.mother complaint loose watery stools of her baby more
than 3x a day.This is the first time that her baby experience LBM.She also stated that
she knows that her baby feels pain because she’s been so irritable and always
crying.She decided to go to her baby’s pediatrician to sick medical help because it’s
been a week but still her baby had loose bowel movement.Pt.said she dont know that
cause of her baby’s lbm.Pt.initial diagnosis was AGE w/ s/sx of DHN,URTI.

D. Past Medical Hx.

Pt.mother stated that this is the first time her baby got confined in the hospital,aside
ofcourse during her hospital delivery.Even though sometimes her baby is sick she just
gave her tempra and after a few hours it’s relieved.

E. family Hx.of illness

Upon interviewing pt. said they dont have any hereditary disease,but she’s not so sure
if her husband family have.But her first born child 6 yo.now also experienced severe
LBM when she still a baby.

F. Social and Lifestyle Hx.

Pt.mother stated that her baby is very active always love to play even in her younger
age.She drinks a lot of milk she consumed more that 6 bottles a day. Her milk formula
si enfalac and water is wilkins.She also started to feed her baby solid foods like gerber
and lugaw.

GORDONS’S FUNCTIONAL HEALTH PATTERNS

Health-perception/health-management pattern
 Patient’s mother stated that she fully understand her baby’s diagnosis and
know the proper management of the disease.Her baby currently have hepa b
vaccine given by her pediatrician and she make sure that she will get all the
necessary vaccine that her baby should have.

Nutritional-metabolic pattern
 Pt. milk formula is enfalac and her water is wilkins.Pt.mother also stated that
she started to feed her baby solid foods like gerber and lugaw.
Elimination pattern
 Pt.stated that her baby consumed 6-8 diapers a day.Her usual bowel movement
is 1-2 times a day.

Sleep-rest pattern
 Pt. mother stated that her baby sleep more often.But wake up easily if there is
a sudden movement she felt.But she make sure that her baby get a good sleep
at night.

Cognitive-perceptual pattern
 Pt. is no sensory deficits,responsive to people.Responds appropriately to
verbal and physical stimuli.

PHYSICAL ASSESSMENT

1. Vital Signs
 Temperature 36 degrees Celsius taken axillary
 Apical pulse 142 bpm @ regular rhytm
 Regular respiration @ 42 bpm

11. General Survey


 Height
 Weight
 Respond to people she see
 Looks appropriate to the stated age
 no signs of distress
 fairly nourished

111. System Assessment


Skin Head and Face
 Smooth  Symmetrical
 Pinkish  Scalf no dandruff w/ minimal
 Warm to touch scaly
 Good skin turgor  minimal smooth hair
 Dark brown in color

Nails Eyes
 Pinkish  eye brows symmetrical
 Intact nail folds  Intact eyelids
 soft nails  normally aligned eyeballs
 conjunctiva pinkish
 clear cornea iris regular
 Blink reflex present
 eye color even
Ears Nose
 symmetrical  symmetrical
 no discharges  septum divided
 turbinates pink
 discharge absent
 nostrils patent
 nasal mucosa pink
 sinuses tender
Mouth Teeth
 Lips symmetrical  No teeth
 no present of lesion  gums pinkish and moist
 Lip color pink  tounge pinkish
 lip texture smooth  buccal pinkish
 tonsils redish
 palate pinkish
 uvula present

Neck Breast
 symmetrical  symmetrical
 pulsation present  pinkish

Abdomen Female reproductive


 symmetrical  no masses
 rounded  no discharges
 midline umbilicus  no edema
 no lesions
musculo-skeletal
 arms and legs symmetrical
ANATOMY AND PATHOPHYSIOLOGY

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.

LAB.Exam/Dx.Exam

PLATELET COUNT
September 23,2009
RESULT NORMAL CLINICAL
VALUES SIGNIFICANCE
281 150-350 x 9/L

COMPLETE BLOOD COUNT


Sepetember 23,2009

EXAMINATION RESUL NORMAL CLINICAL


MADE T VALUES SIGNIFICANCE
Hemoglobin 12.50 13-17 g/L Normal
Hematocrit 0.35 0.4-0.5 Normal
Red Cell Count 4.79 4.5-5.5 ↓
WBC Count 10.28 5-10 ↑
Neutrophil 0.180 0.55-0.65 Normal
Lymphocyte 0.800 0.25-0.35 ↑
Monocyte 0 0.02-0.1 ↑
Eosinophils 0.020 0.02-0.04 ↑
Basophils 0 0-0.05 Normal
Platelet 511.00 140-340
MCV 73.50 86-100
MCH 28.10 28-31 Normal
MHCHC 35.50 31-37 Normal

ROUTINE URINALYSIS

September 23,2009
EXAMINATION RESULT NORMAL CLINICAL
MADE VALUES SIGNIFICANCE
Color yellow Amber yellow Normal
Character turbid Clear Infection
Reaction/pH 6.0-Acidic 4.8-8.0 Normal
Specific gravity 1.020 1.015-1.025 Normal
Protein +++ (-) Infection
Sugar (-) (-) Normal
Red blood cells 0-3 hpf (-) Infection
Pus cells Many(>100/ (-) Infection
hpf)
Epithelial cells Few (-) Infection
Amorphous Few (-) Infection
phosphates
Bacteria any Infection

COURSE IN THE WARD

September 23,2009
Pt. admitted to the ER complaining of loose watery stools for 1 week
already.Her initial VS was taken by the NOD .The ROD admitted the pt. since the
pt.has a referral from her pediatrician.The refferals consist of ordered to be done to
pt.This a sfollows;Full diet to watcher,CBC,u/a,stool exam,nystatin (mycostatin) 1 ml
as oral swabs + 1 ml per orem 4x a day.erceflora 1 vial 2 x day,ped zinc drops 0.3 ml
daily,nebulization.
Endoresement was made properly to NOD in the ward.At around 6:30pm
ROD made a ff rounds to all pediatric pt. and she made a ff ordred to the pt. to
Continue feeding in an upright position.

September 24,2009
Morning care was done to pt at the start of duty,medicine given accurately.Pt
mother still complained of watery stool of her baby.VS taken on time no recorded
increase vs of the baby. At around 12:45 nn ROD made a ff rounds again and ordered
to continue oral medications of the baby.

Sepetember 25,2009
At around 12;20 am pt.AP visit her pt. and made a ff ordered
amikacin,cefalexin drop 1 ml and scheduled her for KUB UTZ.Pt.mother verbalized
improvement of her child stool.At 11am pt.AP called and made an ordered that if
UTZ is normal pt. may go home already. 12:35 nn UTZ was done and after several
hours the result was gather ,normal result was interpreted.Discharge planning was
done and after the pt.go home nurse inform the SO about the take home meds and the
follow-up check up.
DISCHARGE PLANNING 09-26-2009

M- MEDICATION

Instruct pt.SO about the proper way of taking her medicines and the actions of
each meds. in the manner that pt.can easily understand and empasizing the importance
of following the prescribe medication.

E-ECONOMY
Inform pt.about the generic name of her meds.Thus informing them that they
can save money buying generic drugs.

T-TREATMENTS
Advice pt. SO to follow all prescribe medications.Encourage also to increase
pt.fluid intake tolerated by the pt.

H-HEALTH TEACHINGS
Educate pt. SO,s about her disease,how they can prevent it to happen
again.Encourage to increase fluid intake and fruit juices intake as well.

O-OUT PT./REFERRALS
Inform that she have a follow-up check-up after 1 week to his AP clinic..

D-DIET
Educate client that her diet is a s tolerated but emphasizing the need to
increase her oral fluid intake.
Urinary Tract
Infection
A case study
LIEZL T. BINALUYO
BSN 3-1
GROUP 1
CI-MRS.SAMOSA