Download Mia Anderson Situation Mia is a 31-year

Mia Anderson
Situation
Mia is a 31-year-old woman who is 24 weeks pregnant with her 1st baby. Her admission complaints are
flank and suprapubic pain plus dysuria. She states that urgency, nocturia, and frequency are unchanged
“but I go a lot since I became pregnant.” She says, “I usually work the register at the grocery store in the
evenings but I had to call in sick yesterday because I was so tired and nauseated.”
Background
Medical History: She reports that she has had cystitis a few times in the past but none since she married
1 year ago.She also reports a having kidney stones twice in the past 7 years. This is her first pregnancy.
Remainder of medical history is normal.
Social History: Married, lives in student housing on campus. She is attending college for physical
therapy and works part time as a cashier to cover tuition costs. Her husband works as an engineer. They
have no family close by for support but rely on a few close friends.
Assessment
Physical Exam:+
Head: Normacephalic, normal hair distribution, Face: Puffiness around eyes (peri orbital edema) no
conjunctival pallor. EOMs intact PERRLA
Thorax: AP:Transverse 1:2 ration, non labored breathing, lungs clear all fields, HR no murmurs
T, 102 F; P, 114; R, 22; and BP, 130/90.
Abdomen: Gravid uterus, no lesions or scars noted no tenderness to palpation anteriorly,
.+ CVA tenderness right side of flank region posteriorly
UE: ROM + no pain, strength equal, cap refill <3 sec, rings tight, 2+ radial bilaterally
LE: ROM + no pain, strength equal, cap refill <3 sec, ankle edema bilaterally
Diagnostics
Her urine is cloudy, amber, and foul smelling, positive for both leukocyte esterase and nitrate, with white
blood cells and gram-negative bacteria.
CBC: RBC 5.2,Hgb 14 Hct:42% WBC 26,000, neuts 70% bands 10%, lymphs15%, mono 3%, eos 1%,
baso 1%, platelets 300,000
UA: + protein, + nitrates, +leukoesterase, + blood +WBC culture _+ gram – cocci
1. What additional assessment data should you obtain?
History: Have you ever been told that you have unusual or malformed kidneys or urinary structures? Have
you noticed any vaginal discharge? Have you ever been told you have high blood pressure
(hypertension) or high blood sugar (diabetes)?
Subjective: Ask about location, duration, onset, and relieving factors related to pain. Ask if she has
notice a change in the color, amount, or odor of urine with her symptoms.
Objective: CBC and urinalysis are available, evaluate the CBC for leukocytosis (elevated white blood
cell count) and a left shift in the differential. Evaluate the urinalysis for the presence of leukoesterase,
nitrite, protein, hematuria, and white blood cells. Her urine is cloudy, amber, and foul smelling, positive for
both leukocyte esterase and nitrate, with white blood cells and gram-negative bacteria.
Physical Exam:+ CVA tenderness right side
T, 102 F; P, 114; R, 22; and BP, 130/90.
2. Which manifestations are specific to cystitis, which are specific to pyelonephritis, and which are
common to both? Make a table comparing these two urinary problems.
Cystitis
Pain suprapubic, bladder 2nd spasms, intermittent
Frequency urgency, hesitancy, dysuria, pyuria
Somatic: afebrile, no nausea, no chills, WBC
normal
Pyelonephritis
Pain: flank CVA tenderness
Frequency, urgency, hesitancy, dysuria, pyuria
Somatic: fever, chills, nausea, vomiting WBC
elevated
3. What risk factors for pyelonephritis are present for this patient?
:pregnancy, history of cystitis, kidney stones,
Mia is diagnosed with acute pyelonephritis. Because she is pregnant, she is considered a “complicated”
presentation of pyelonephritis. A urine culture is obtained along with a Gram stain that shows grampositive cocci.. The perineal examination indicates that her urethral meatus is located abnormally close to
her vagina. She will undergo cystography after she recovers from her delivery of her child in 6 to 12
months from now. Further testing is deferred because of her pregnancy. Her serum creatinine is normal at
1.0, which indicates adequate renal function, further indicating that additional diagnostic testing can be
deferred.
1. Explain whether this patient’s acute pyelonephritis is an ascending or a descending infection.
Ascending—Most renal parenchymal infections occur from bacterial ascent through the urethra and
urinary bladder.
2. How do the findings of the physical examination relate as a cause of her acute pyelonephritis?
Because the outlet for her urethra is near her vagina, there is a possibility she has an undiagnosed
anatomic defect in her urinary tract. The most common defect is the vesicoureteral reflux from a stricture
or congenital anomaly.
Recommendation:
Mia’s admission orders include: She has no known drug allergies;
a.
b.
c.
d.
e.
f.
g.
Lactated Ringers 1000mL every 12 hours
Ceftriaxone 2g IVPB daily
Acetominophen grX po for c/o mild pain and tem > 100 degrees F
Regular diet encourage fluids po
BR/BRP
FHT every 8h
I/O
1. What pregnancy category is Ceftraxone? B
FDA PREGNANCY
CATEGORIES
The FDA-assigned pregnancy categories as used in the Drug Formulary
are as follows:
Category A
Adequate and well-controlled studies have failed to demonstrate a risk
to the fetus in the first trimester of pregnancy (and there is no evidence
of risk in later trimesters).
Category B
Animal reproduction studies have failed to demonstrate a risk to the
fetus and there are no adequate and well-controlled studies in pregnant
women.
Category C
Animal reproduction studies have shown an adverse effect on the fetus
and there are no adequate and well-controlled studies in humans, but
potential benefits may warrant use of the drug in pregnant women
despite potential risks.
Category D
There is positive evidence of human fetal risk based on adverse
reaction data from investigational or marketing experience or studies
in humans, but potential benefits may warrant use of the drug in
pregnant women despite potential risks.
Category X
Studies in animals or humans have demonstrated fetal abnormalities
and/or there is positive evidence of human fetal risk based on adverse
reaction data from investigational or marketing experience, and the
risks involved in use of the drug in pregnant women clearly outweigh
potential benefits.
2. What is the hourly rate for Mia’s IV? She is on a gravity IV. The drop factor for the tubing is
10gtt/min. Solve for mL/h and gtt/min.
1000/12=83.33 so 83
83x 10/60=14gtt/min
48 hours have passed and Mia’s condition has improved so she is being discharged.
1. What discharge teaching do you feel is important for Mia to have once she is able to go on
outpatient antimicrobial therapy
ABX 14-21 days finish all!
Office visit within 3 weeks, f/u urine culture
2. What could you suggest as measures for this patient to reduce her risk for future episodes of
pyelonephritis and cystitis?
a. She should maintain sufficient fluid intake to maintain a dilute, light yellow or clear-colored
urine during both day and night. 8 glasses of water/d
b. f/u with the urologic testing once she heals and recovers from delivery.
c. avoid the use of a diaphragm or spermicidal jelly, using another method of birth control.
d. She could consider drinking 50 mL of cranberry juice daily to reduce adherence of bacteria to
the urinary tract.