NURS1202: Comprehensive Case Study of a Female Patient with a UTI

This case study presents the assessment and management of a 35-year-old female patient with a urinary tract infection (UTI), hypertension, T2DM, and chronic kidney disease. The case includes a detailed health history, including current medical conditions, past medical and surgical history, medications, and lifestyle factors. The student collected cues through physical and pain assessments, and identified important information like hypertension, diabetes, and pain levels. The study outlines the necessity for additional assessments such as fluid imbalance, neurological, and nutritional assessments. The analysis incorporates relevant literature to understand the physiology, pathophysiology, pharmacology, and therapeutics related to the patient's conditions, focusing on medications like captopril, metformin, and oxycodone. The student interprets assessment findings, identifies key problems such as acute pain and fluid imbalance, establishes nursing goals (pain reduction), and proposes nursing interventions, with rationales based on evidence-based practice. The case study emphasizes the importance of pain management and fluid balance in UTI patients, and the need for ongoing monitoring and evaluation.

Health History
Gender Female
Age 35
Current Medical History
What current medical conditions do you
have?
She is associated with urinary tract infection (UTI) with severe suprapubic pain and fever. She is
associated with reduced urine output and increased urgency.
Data related to his vital signs and other clinical symptoms was collected from his case reports: RR
24, Sats 93% on RA,
Circulation: HR 97 bpm,
BP 170/100 mmHg,
She described her pain as achy, burny and gripping. Her daytime frequency is 12-14 and nocturia is
3-4 voids.
Her urine is dark-colored.
Past Medical/Surgical History
What is you past medical/surgical history?
Medical History
T2DM, Ex-smoker (5 years before), HTN,
Hyperlipidaemia, chronic kidney disease stage
3 (Baseline eGFR 40 ml/min/1.73m2), chronic
venous leg ulcer to L) leg, anxiety. No known
declared allergies (NKDA). She is obese
(BMI 30) and drinks 1 bottle of wine every
night. She mentioned that previously she
visited two urologists and two gynaecologists.
Surgical History
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She is using antimuscarinics, trimethoprim-
sulfamethoxazole, tricyclic antidepressants
and oxycodone. She reported chills and
feverShe has had 2 prior UTIs in the past year,
which were successfully treated each time
with trimethoprim-sulfamethoxazole (TMP-
SMX) 160 mg/800 mg twice a day for 3 days.
The last UTI was 4 months ago which was
associated with pyelonephritis.
Medications
What medications do you take?
List medications and dosages (where possible)
She is administered with medications such as paracetamol (650 mg), oxycodone (20 mg extended
release tablets per day), metformin (500 mg every 12 hours) and captopril (25 mg PO q 8-12 hr).
Do you live alone/with someone? With someone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
Yes
No
No
No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes
No
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Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
No
No
Do you wear dentures?
Are they upper/bottom dentures?
No
Do you drink alcohol?
How often do you drink?
How many drinks do you have each day?
Yes
1 bottle per night
Do you smoke?
How many cigarettes do you smoke a day?
Ex-smoker
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
Yes
Diabetic diet
150 cm
75 kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
No
No
Do you have any wounds?
Where are they?
Yes
1) Nursing assessment tool used – Result – Physical and vital sings were performed for Ms. ABC. Different procedures were
performed to carry out physical assessment such as observation, auscultation, percussion and
palpation. Physical assessment reported that her skin, face, eyes, chest, abdomen, elbows and joints
were normal. Lymph nodes, chest wall and abdomen were normal; however, lumps were observed in
the leg region. Lub-dub sound was observed in heart and murmurs were observed in the heart sound.
Lungs produced normal sounds; however, abdomen produced abnormal bowel sound. Observed vital
sings were RR 24 bpm, HR 97 bpm, Temp 38.6̊ and BP 170/90 mmHg. Moreover, bilateral pitting
oedema was observed on her calves. During neurological observation, lack of coordination was
observed (Lambe, Currey, and Considine, 2017).
2) Nursing assessment tool used – Result – Pain assessment in Ms. ABC was performed using PQRST algorithm. Pain assessment is
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important aspect in her because it is one of the most important symptoms of UTI. Moreover, pain
assessment is also useful in the selecting appropriate medications for the pain management. Pain
assessment was performed by asking questions such as P = Provocation/Palliation, Q =
Quality/Quantity, R = Region/Radiation, S = Severity Scale and T = Timing. Pain assessment was
performed at different time points of the day to obtain valid data because pain assessment is a
subjective method. Hence, based on the physical and psychological status of the patient, pain
assessment might vary. However, pain assessment data was consistent at different time points of the
day. Reported pain in Ms. ABC was 7 on 0 – 10 scale. Hence, should be considered as severe pain
(Varndell, Fry, and Elliott, 2017).
3) Any other nursing assessment tools used
-
Result –
Any other information you wish to add in relation to the person you interviewed.
Assessment 1 – Case Study Template
1) Consider the Individual (25 words)
Ms. ABC (35) years will be considered for care who is associated with Urinary Tract Infection (UTI).
2) Collect cues/Information
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Current information- including your 2 assessments: (cues collected during the interview) (250 words)
During interview, cues were collected related to the physical and vital signs assessment and pain assessment. Cues related to the hypertension were
collected through obtaining information of anti-hypertensive medication such as captopril 25 mg PO q 8-12 hr. Captopril in useful in normalisation
of blood pressure. However, it was observed that captopril was not reducing blood pressure in Ms. ABC to the normal level. Moreover, Ms. ABC
also reported that she was experiencing signs and symptoms such as severe headache, fatigue, vision problem, and breathing difficulty. These
symptoms indicate hypertension in her. Acute pain exaggerates hypertension (Saccò et al., 2013). Ms ABC also reported that she was experiencing
exaggerated symptoms of hypertension during pain episodes. Moreover, vital sings such RR and HR also increase due to episodes of acute pain.
Information about acute pain was also collected from the medications administered pain management. Oxycodone was being administered in her
with dose of 20 mg extended release tablets per day (Gabayan et al., 2017). Information about T2DM was collected from the antidiabetic
medications. Ms ABC mentioned that she was associated with T2DM since last 3 years. However, she was managing it with exercise and diet for
initial 2 years. However, since last 1 year she was consuming metformin for the management of diabetes. She was consuming metformin 500 mg
every 12 hours. However, it was evident that her glucose level was not being effectively kept normal after consumption of metformin. T2DM in Ms
ABC was also evident from symptoms such as frequent urination, increased thirst, frequent feeling hungry, feeling tired, and blurry vision (Nitzan
et al., 2015).
Gather new information: (identify 3 other assessments that you could conduct regarding this person and the importance of these
assessments) (200 words)
Fluid imbalance assessment should be conducted in Ms. ABC because fluid imbalance is the significant effect of UTI. Hence, this assessment is
necessary in her because fluid imbalance assessment would be helpful in planning early intervention to sustain normal fluid imbalance. Moreover,
normal fluid imbalance is also beneficial in restoring the vital signs in the normal range (Davies, Leslie, and Morgan, 2017). Neurological
assessment is essential in case of Ms. ABC to assess level of consciousness and mental status using Glasgow Coma Scale. Persistence of pain for
longer duration and higher level of glucose level for the longer duration results in neurological abnormalities such as disturbed orientation to
person, time and place. Moreover, neurological abnormalities were also evident during interview with Ms. ABC. Hence, it is necessary to perform
detailed neurological assessment to get more insight in mental health status. It is necessary to detect hypovolaemia or hypervolemia in Ms. ABC
because it might lead to pulmonary oedema, hyponatraemia or hypovolaemic shock. Nutritional and dietary assessment should be performed using
anthropometric measurements method. Different parameters such as body weight change, skin fold thickness and arm circumference should be used
for dietary assessment. In patients with UTI, sudden body weight change can occur due to fluid loss (Prowle, Kirwan, and Bellomo, 2014).
Recall (using literature identify and describe 3 cues in relation to physiology, pathophysiology, pharmacology, epidemiology, therapeutics,
contexts of care or ethics that will assist you to further understand this personal health) (300 words)
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Hypertension is one of the most common complications of the urinary tract infection. Hypertension might result in the reduced supply of white
blood cells to the urinary tract for fight against infection. For the management of hypertension in Ms. ABC captopril should be used which exhibit
its action through acting as competitive inhibitor of angiotensin I-converting enzyme (ACE) which is responsible for conversion of angiotensin I to
angiotensin II. Dosage adjustment is essential for captopril in patients with renal impairment because captopril mainly excreted through kidneys.
Excretion rate of captopril get reduced in UTI patients; hence, it takes longer time to reach steady-state. Therefore, less frequent doses of captopril
should be administered in such patients (Antunes et al., 2016).
UTIs are more common in people with diabetes because increased levels of glucose level can lead to risk of UTI. Moreover, diabetes patients might
have poor circulation which results in the inability of white blood cells to travel to fight against infection. Metformin exhibit its action through
reducing hepatic glucose production, reducing intestinal glucose absorption and through improving insulin sensitivity by increasing peripheral
glucose uptake and utilization. Metformin is contraindicated in patients with higher GFR. However, in patients with low GFR, health risks and
benefits should be evaluated on regular basis. GFR should be monitored more often in patients with metformin administration (Thomas and Gregg,
2017).
Urethral infection usually causes dysuria (pain during urinating). Bladder infection also lead to suprapubic pain. In addition to the administration of
analgesic, increased consumption of water is beneficial in reducing irritation which can be helpful in reducing pain. Oxycodone exhibit its action
through binding to receptors which inhibit adenylyl-cyclase and hyperpolarisation of neurons which reduces neuron excitability. Regular
monitoring of urine output is necessary in patients with oxycodone administration because it results in bladder relaxation and urine retention
(Coluzzi, 2018).
3) Process information
Interpret – (Identify the normal versus abnormal values of 5 cues collected during the assessment and describe your client/patients
assessment/history results) (100 words)
Normal BP in adults should be between 120/80 mmHg in adults; however, recorded BP in Ms. ABC was 170/100 mmHg. Normal blood sugar level
in adults should be below 140 mg/dL; however, reports indicated that blood sugar level in Ms. ABC was 280 mg/dL. Oliguria is the condition in
which urine output is less than 400 ml per day. In case of Ms. ABC, low urine output was observed her output was 300 ml in the last 24 hours. On
pain assessment scale, recorded pain scale was 8 which indicate severe pain. She was infected with Staphylococcus saprophyticus.
Discriminate – (Identify the two most important results/cues and why you consider they are important) (150 words)
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Pain as a clue is important in case of Ms. ABC because management of pain is important component of the UTI patients. Pain not only affect the
physical well-being but also affect psychological health of the patient. Pain is important clue in UTI patients because pain with variable intensities
persists in these patients for more than 6 months. Pain as clue evident in UTI patients in the form of burning on urination, facial grimace, guarding
behaviour, protective and reduced physical activity and spasm in lower back and bladder area (Coluzzi, 2018).
Fluid imbalance is important clue in UTI patients because it is beneficial in to keep potassium and sodium level in normal range. Normal fluid
balance is important in UTI patients because it is helpful in eradicating microorganism from the body through making pathogens more difficult to
adhere to the human cells (Prowle, Kirwan, and Bellomo, 2014).
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4) Identify problems/issues
(50 words)
What is the issue for the patient/
individual?
5) Establish Goals ( 50
words)
What do you want to achieve as an
outcome?
SMART Goals
6) Take Action ( 100 words)
What will you do here in the way
of care for the patient/individual?
7) Rationalise your nursing
action (300 words total)
Why have you chosen the actions
you want to do for the
patient/individual? With references
to support your rationales
First Nursing Problem
Acute pain related to the UTI.
One Nursing Goal –
Reduce pain sensation and
minimise pain rating on pain scale
below 3 through accurate
assessment of pain using PQRST
algorithm prior to and
administration of analgesic
medications and using non-
pharmacological interventions
within 2 weeks duration.
First action –
Observe, monitor and interpret
both verbal and non-verbal
communications in Ms. ABC.
Encourage Ms. ABC to verbalise
pain and report pain sensation and
related symptoms immediately.
Acknowledge the pain reports of
her and disseminate and
communicate this information to
the physician.
Rationale –
Most of the patients with pain
sensation are not willing to
verbalise their pain sensation.
Hence, clues gathered through
non-verbal communication can be
useful in the assessment of pain.
Hence, information related to pain
can be provided to physician and
relevant intervention can be
planned. Immediate reporting and
relevant reporting are essential in
patients with persistent pain
because it can produce
psychological problems such as
depression and anxiety. Moreover,
prompt reporting of pain is useful
in establishing positive therapeutic
relationship among patient and
nurses (Duke, Botti, and Hunter,
2012).
Second action –
Encourage Ms. ABC to consume
Rationale -
Analgesic medications proved
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analgesic medication on scheduled
timings and ensure she is following
the schedule. Ensure Ms ABC
adhered to medication
consumption. Moreover, monitor
and assess efficacy and safety of
analgesic medications. Efficacy
should be assessed using PQRST
algorithm and safety should be
assessed through observations.
beneficial in reducing pain
sensation. Patients with multiple
medications consumption are
usually not adhered to medication
consumptions. Since, there is no
objective parameter available for
the assessment of pain; subjective
scale such as PQRST algorithm
should be used for the pain
assessment. It is evident that
analgesic medications are
associated with side effects; hence
it is essential to assess and monitor
side effects in these patients (Pham
et al., 2017).
Second Nursing Problem
Risk of fluid imbalance.
One Nursing Goal –
Preserve normovolumic condition
and eliminate chances of
hypovolemic and hypervolemic
condition through accurate
assessment of fluid intake and
elimination and keeping accurate
records on fluid-balance chart;
moreover, normal fluid balance in
2 weeks time either through
administration of diuretic drugs or
administration of suitable
electrolytes and water.
First action –
Fluid imbalance chart and fluid
prescription chart should be
updated on regular basis.
Information about the quantity and
schedule of administration fluids
and electrolytes should be updated
on these charts. Record of urine
elimination should also be updated
on the regular basis. Urine
elimination record should be
maintained for both quality and
quantity of urine. Data recorded
for urine elimination should be
Rationale –
Information provided in the fluid
balance chart would be helpful in
deciding quantity of fluid which
need to be administered. Hence,
optimum of fluid can be
administered. Administration of
exact amount of fluid would be
helpful in reducing chances of
development of either
hypovolemia or hypervolemia.
These charts also would be helpful
in selecting relevant electrolytes
which need to be administered.
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compared with the standard data of
the same age group patients. Body
weight should be monitored and
recorded in regular basis.
There is strong correlation exist
between the body weight and fluid
imbalance. Unexpected or sudden
change in the body weight could
occur due to fluid imbalance.
Hence, change in body weight can
be helpful in the assessment of
fluid imbalance (McGloin, 2015).
Second action –
Encourage patient to drink more
amount water and other liquid
nutrients.
Rationale –
Consumption of more amount of
water and other liquid nutrients
would be beneficial in restoring
normal fluid balance. Inadequate
amount fluid can lead to drying of
mucous membrane. Moreover,
fluid restriction can lead to
deficient amount of sodium and
potassium in the body
(Pinnington, Ingleby, Hanumapura,
and Waring, 2016).
8) Reflect on process and new learning (250 words)
I could have implemented cognitive behavioural therapy for Ms ABC to improve her clinical condition as a matter of fact that she might be
suffering from psychological disorder. I could have provided education about the infection prevention to Ms. ABC. I understand that education
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about the infection prevention can be beneficial in preventing infection in the future and infection prevention is achievable goal which can be
achieved in the absence of healthcare professionals. I realised that I should incorporate family members while providing care to such patients. I
learned that incorporation of family members in the care would be helpful in providing education to family members. I understand that
collaborative work of family members and healthcare professionals would be beneficial in providing effective care to the patients. If I would have
skills and knowledge about the cognitive behaviour therapy, it would have been helpful in minimising the chances of anxiety and depression in Ms.
ABC due to persistent pain. I understood that medication adherence is the important aspect in providing effective care to the patients. Moreover, I
learned that not only pharmacological intervention but also non-pharmacological interventions are also necessary for providing effective
intervention to such patients. In summary, I learned complete cycle of clinical reasoning cycle comprising of different steps such as collection of
information and cues, processing of collected information, identification of problems and issues, establishment of goals, taking action and
evaluation of outcomes.
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Pham, P.C., Khaing, K., Sievers, T.M., Pham, P.M., Miller, J.M., …Pham, P.T. (2017). 2017 update on pain management in patients with
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