S: CD, new client, is a twenty nine year old Asian female complaining of urinary frequency, burning, and urgency. She states that she has experienced these symptoms and that her urine has had a foul smell for the last three days. CD is thirty weeks pregnant with her second child. She has been married for four years and is a mother of an eighteen month old boy. Her first child was delivered via vaginal birth with an uncomplicated pregnancy at thirty eight weeks.
CD denies any other pregnancy or abortions. She also denies allergies to any medications. She has never taken any medication OTC. The client is compliant with Rx prenatal vitamins as ordered by her OB. FH and PMH are noncontributory. Her pregnancy has been uneventful and healthy to this point. Fetal movement is normal.
The client only complained of a burning sensation when urinating. The urination was more frequent and urgent. The urine was also cloudy and produced a strong nasty smell. The client has not had UTI or diabetes in the past.
O: Generally CD appears tired and distressed
Vital Signs: BP is 110/60, HR is 88; Resp 22, T 98.8, Ht. 64 inches, Weight 146 lbs.
Fetal heart action: normal: 120-160 BPM
Respiratory: Bilateral Breath Sounds (BBS) w/good air exchange
Cardiovascular (CV): (HS-Heart Sounds): S1, S2, No m/r/g, Regular Rate & Rhythm
Gastrointestinal: BS present, soft, no TTP, heme neg
Musculoskeletal: UE and LE - FAROM w/o pain /erythema/deformity/TTP
Urine: cloudy with a strange smell;
Urinary tract: presence of significant number of bacteria 103 organisms/mL
A: the client is experiencing normal body functioning except for urinary frequency, burning, and urgency. The urine is also producing a strong nasty smell, which is disturbing the patient. The infection is asymptomatic as it does not produce any other symptom in the patient’s body.
From the subjective section, we see that CD only complained of a burning sensation when urinating. The urination was more frequent, urgent, cloudy and produced a strong nasty smell. The client also had not experienced the same symptoms in the past. During her pregnancy, the client had followed instructions given to her by her doctor.
The objective section showed that the patient was healthy with no other symptoms in her body. Her other organs were well functioning with no infection. The pregnancy was also normal till that moment as the fetal heart action was ranging in a normal margin of 120-160 BPM.
The pain experienced during the passage of urine may have been as a result of cystitis. This is a bladder infection that is common to pregnant women like CD. Its symptoms also include frequent passage of urine.
P: action depends on the type of bacteria identified at the urinary tract. A sample of urine will be used to identify the type of bacteria before administering antibiotics. The recommended antibiotics include amoxicillin, sulfisoxazole, cephalosporins and sulfamethoxazole/ trimethoprim. The recommended type will depend on the severity of the infection. Blood samples can be taken as a precautionary measure to identify any adverse effects. This will help reduce further infections. The patient will also be advised accordingly in order to avoid situations of re-infection.