Student’s Name
Institution Affiliation
Urinary Tract Infection
Urinary tract infection (UTI) is considered to be a common health problem and occurs as a result of the microbial invasion. Normally, urine is sterile, that is, it is free of bacteria, fungi, and viruses. Some of the parts affected by UTI include the bladder, the kidneys, urethra, and the ureters, and it is therefore classified into two types depending on the parts infected. The two types of UTI are cystitis and pyelonephritis with the former affecting the lower urinary while the latter affects the upper tract. Just like other acute infections, the initial step in the treatment of UTI includes the use of antibiotics. A comprehensive plan for patients suffering from the disease will be put to detail, including tests taken, and the recommended plan of care.
Subjective Data
The patient is a 28-year-old female who have identified that they have been experiencing som burning sensations and pain whenever they urinate. Also, the patient has also determined that they have been experiencing some increased pain in their lower abdomen and some vaginal discharge for the last one week. Some of the complaints brought forward by the patient include that they have been experiencing symptoms similar to those they have experienced before. She also noted that they had had some foul smelling discharge every time they engaged in unprotected sex with her former partner. The patient’s medical history also indicated that they had had recurrent UTIs with three such cases this year. Additionally, the patient has some history of gonorrhea x2 infections, Gravida IV, Chlamydia X1, and Para III. The patient also had some past surgical history having gone through some tubal ligation some two years back. Checking on the patient’s family history, they have had multiple male sexual partners and is now living with their new partner and three children. However, they had an excellent social history since she denied of ever smoking, using alcohol among other drugs. Her medical history indicated that she has bee prescribed with Trimethoprim (TOM) and Sulfamethoxazole (SMX).
Objective Data
Objective data, in this case, means the observations and measurements taken by the care provider.
Physical Examination
Some of the information gained by the nurse practitioner regarding the patient include that they seemed to be in moderate distress. Other results are BP100/80, RR 16, HR 80, a temperature of 99.7 ft, and 5 feet in height. Physical examination on the cardio indicated that the patient had a rhythm normal S1 and S2 and a regular rate. The abdomen was found to be tender and soft with an increased suprapubic tenderness. Both chest and Rectal were found to be within the normal limits. Concerning the genitourinary (GU), it was found that the patient’s cervical motion and the adnexal were tender. However, the vaginal drainage produced some foul smell. Lastly, the patient’s neuro was found to be within the normal limits.
Laboratory and Diagnostic Testing
The nurse practitioner indicated that the patient’s leukocyte differential as follos:
Neutraphils: 68%
Bands: 7%
Monos: 8%
Lymphs: 13%
EOS: 2%
On conducting a urinalysis (UA), the following results were obtained,
Sp gr 1.015
The urine was straw colored
Protein, gluscose, and ketones were negative.
There were many bacterias in the urine.
Leukocytes 10-15
Urine gram stain – gram negative rods
Vaginal discharge culture was as follows:
Neisseria gonorrhea
Gram negative diplococcic
Othe results were Chlamydia which indicated a positive monoclonal.
After assessing the patient’s medical history, the symptoms, and the lab results, the patient is diagnosed to be suffering from a urinary tract infection. Some of the reasons behind the diagnosis include the foul smelling discharge, the history of recurrent UTIs, and the burning sensation and pain while urinating.
Plan of Care
UTI is best treated by using antibiotics. Specifically, phenazopyridine is the most recommended prescription for a patient with the infection as it alleviates the symptoms (Balakrishnan & Hill, 2010). Additionally, since the patient does not indicate an incident where they have been allergic to any medicine, the patient can be prescribed with 3grams of Fosfomycin trometamol where the patient is supposed to get a single dose on a daily basis (Balakrishnan & Hill, 2010). The other option of treatment is the prescription of Pivmecillinam 400 milligrams to be taken for five days (Balakrishnan & Hill, 2010).
Evaluation of Primary Diagnosis
Acre giver should not let their patients leave their settings without having to advise them on how to best cope with an ailment. In this case, the nursing practitioner should ensure that they have provided the patient with ways of coping up with the infection and also foster some sense of personal control (Balakrishnan & Hill, 2010). The nursing practitioner should also respect the decision of the patient on whether they want to disclose their condition to the public. The medical condition, in this case, is not visible to other individuals and therefore the patient can decide to conceal the information and maintain a healthy outward appearance (Balakrishnan & Hill, 2010).
Facilitators and Barriers
During the diagnosis and treatment of UTI, it has been noted that the primary challenge comes in when the practitioner offers the wrong medication which causes the infection to recur (Gibson & Toscano, 2012). Wrong antibiotic prescription also exposes the patient in contracting other related diseases (Gibson & Toscano, 2012). These carriers can be overcome by carrying out detailed tests and going through past medical histories to avoid repeating similar mistakes made (Gibson & Toscano, 2012).
In conclusion, a comprehensive plan for patients suffering from urinatry tract infection have been put to detail, including tests taken, and the recommended plan of care. It has been established that the inefection is common among people and is treatavle in clinics provided that detailed tests are conducted to avoid the infection from recurring.
Balakrishnan, I. N. D. R. A. N., & Hill, V. (2010). Dealing with urinary tract infections. The Pharmaceutical Journal, 287, 687-690.
Gibson, K., & Toscano, J. (2012). Urinary tract infection update. Am. J. Clin. Med, 9(2), 82-86.