NCM 109 A

GUT INFECTIONS
 Urinary Tract
Infection (UTI)
- It is an infection found within the urinary tract which can
be caused by a bacteria (most common), virus, or fungus--- E.
Coli, Klebsiella, Proteus
- The female urethra (4.8-5.1 cm) is shorter than the males
which allows for easier migration of an infectious agent to
the bladder and the close proximity of the urethra and the
rectum increases the chances of the bacteria in the GI tract
infecting the urinary system
- The single most important HOST factor is URINARY STASIS
- If left untreated it can cause PTL; Sexual activity >UTI
UTI can be found anywhere throughout the urinary system
such as:

➢Lower Urinary System

Urethra (Urethritis)
Bladder (Cystitis)

➢Upper Urinary System

Ureters (Ureteritis)…usually associated with bladder or kidney infection
Kidneys (Pyelonephritis)
Physiology of how urine flows downward:
(Structures responsible)
▪ Ureterovesical Valves: these are one-
way valves that connect at the ureters
and bladder to prevent the backflow of
urine into the ureters from the
bladder. One-way
valves
▪ Muscles of the Bladder: these muscles
help squeeze the urine out of the
bladder and prevent residual urine.
▪ Pressure created by the urine in the
bladder: this keeps the urine traveling
downward.
- UTIs typically start in the urethra and
spread upward to the bladder and can be
found in both the lower or upper tract. If
the infection is not treated promptly and
correctly, it can spread to the ureters and
kidneys.
- Pyelonephritis is extremely dangerous
because the infection can enter the
bloodstream and lead to sepsis--------------
(kidneys are very vascular and work closely with the heart)
Etiology:

✓ Ascending bacterial infections

✓ Another cause of UTIs is retention and residual urine due
to overdistention and incomplete emptying of the bladder
(URINARY STASIS)
* Temporary urine retention may be due to decreased
perception of the urge to void, resulting from perineal
trauma and the effects of analgesia, or anesthesia.
* Urinary stasis and residual urine provide a medium for
bacterial growth, predisposing the client to cystitis and
pyelonephritis.
Causes of UTI: “Hard to Void”

Hormone changes: pregnancy, menopause, birth

control (changes the normal flora in the vagina that
normally fights bad bacteria that can migrate into
the urethra).
Antibiotics: changes the normal flora of the body
Renal Stones: cause blockage... urine stays in kidney
and can’t drain
Diabetes: compromised circulation…immune system
not able to work as strong as it should to fight the
infection & high glucose in the urine: breeding
ground for bacteria to flourish, bladder doesn’t
empty as it should (urinary retention from nerve
damage)
Toiletries: excessive bubble baths,
powders, perfumes, especially scented
tampons and sanitary napkins

Obstructive prostatic hypertrophy…seen

in males with BPH: The urethra which is
surrounded by the prostate gland
becomes squeezed shut from the large
prostate gland….urine stays in the
bladder because the patient can NOT
empty it completely, and the prostate
gland isn’t able to properly secrete that
fluid with antimicrobial properties.
Vesicoureteral reflux (VUR): most common in pediatric patients and is
when urine from the bladder backflows into the kidneys. It is usually a
congenital defect to the ureterovesical valves that are found between
the bladder and ureters. They don’t close properly and there is a
backflow of urine into the ureters.

Overextended bladder: bladder is full for long periods of time and the
bladder muscles become weak which leads to urinary retention.
Patients who are immobile are at risk for this.

Indwelling catheters, invasive procedures, intercourse (especially with

the usage of spermicides), incontinence of the bowel

Decreased immune system…can’t fight germs (immunosuppressed) and

majorly at risk for UTIs that are fungal and viral in origin.
CLASSIFICATIONS:
BACTERIURIA – presence of bacteria in the urine
ASYMPTOMATIC BACTERIURIA – significant bacteriuria (more than 100,000 colony- forming units)
with no evidence of clinical infection
SYMPTOMATIC BACTERIURIA – bacteriuria accompanied by physical signs of UTI (dysuria, suprapubic
discomfort, hematuria, fever)
RECURRENT UTI – repeated episode of bacteriuria or symptomatic UTI
PERSISTENT UTI – persistence of bacteriuria despite antibiotic treatment
FEBRILE UTI – bacteriuria accompanied by fever and other physical signs of UTI
CYSTITIS – inflammation of the bladder (dysuria, urgency, frequency, low grade fever)
URETHRITIS – inflammation of the urethra
PYELONEPHRITIS – inflammation of the upper urinary tract and kidneys (chills, fever, flank pain,
dysuria, low UO, elev. BP, N/V)
UROSEPSIS – febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals
presence of urinary pathogen
Dx:
➢ Urinalysis (U/A): assesses for bacteria or WBCs
in urine (collect the urine when the bladder
has been full for about 2-3 hours
➢ Urine culture: to assess what bacteria is
causing the UTI…so antibiotics can be ordered
correctly (COLLECT URINE CULTURE BEFORE
starting the first dose of antibiotics)
➢ Cystoscopy: assesses the inside of the urethra
and bladder (ordered for recurrent infections)
SPECIFIC GRAVITY – Normal 1.010. If elev.- urine is
concentrated, if below normal- urine is diluted
URINE pH – normal (pH 5.0) – urine normally acidic
PROTEIN – Normal- NEGATIVE. If with TRACE (+), kidneys may
have a problem
GLUCOSE – Normal- NEGATIVE. If +, blood sugar maybe high
or possible if under dapagliflozin (blood glucose
lowering drug)
BLOOD - NEGATIVE.
LEUKOCYTES & NITRITE - NEGATIVE. If + , possible urine
infection
KETONES - NEGATIVE. If +, possible high blood sugar,
individuals who are fasting
RBC (RED BLOOD CELL) – abnormal if 2 or more RBC per high-
power field. Commonly caused by UTI, kidney stones o
glomerulonephritis.
WBC (WHITE BLOOD CELL) – Normal- 2-5 per high power
field. If with infection- elevated
EPITHELIAL CELLS – Normal- FEW or NEGATIVE. If result is
moderate, TNTC- it is CONTAMINATED (not properly
collected)(subject for repeat urinalysis)
BACTERIA – Normal- FEW or NEGATIVE
Urine C & S
S/Sx:
➢ Pain when voiding (burning)--- “dysuria”
➢ Persistent need to void but not a lot is voided or can’t void (scanty UO)---
“urinary frequency”
➢ Strong odor to urine that is dark and cloudy (can have blood)
➢ Cramping in abdomen or pain at the costovertebral angle
Costovertebral angle is found under the
12th rib and between the spine (if pain is
experienced a kidney infection may be present
(pyelonephritis).
➢ Spasms of the bladder or urethra---
“detrusor contraction”
➢ Fever
➢ Increased WBC on U/A --- “Pyuria”
PREVENTIVE MEASURES:
• Perineal hygiene
• Avoid tight clothing or diapers (wear cotton panties, rather
than nylon); Avoid caffeine and alcohol…irritate bladder
• Avoid “holding” urine; encourage to void frequently (q 2-3H)
• Empty bladder completely with each void
• Avoid straining during defecation and avoid constipation
• Encourage generous fluid intake (2.5-3L/day)
*** safe meds during pregnancy: BACTRIM
*** UTI can increase risk of PTL
 Sexually transmitted disease (STD)
Sexually transmitted diseases are infections spread mainly
by contact with genitals or bodily fluids. Also called STDs,
STIs or venereal disease, sexually transmitted infections are
caused by bacteria, viruses or parasites.

Sexual activity includes genital touching or sexual

intercourse. Anyone who is sexually active can get an STI.

****unprotected vaginal, anal, or oral sex, multiple sex

partners as well as by sharing sex toys that have not been
washed or covered with a new condom
 STD’s
MONILIAL VAGINAL INFECTION
(Candidiasis, Monilia, Moniliasis, or Vaginal Yeast
Infection)
* caused by an overgrowth of a fungus that naturally lives in the vagina, called Candida albicans
* Candida A. often infects the nails (Onychomycosis), the skin (diaper rash), oropharynx (Thrush)
S/Sx for Superficial C.:
- Skin- scaly, erythematous, popular rash with exudate (usually below the breasts, fingers,
axilla, groin, umbilicus)
- Nails – red, swollen with darkened nail beds (separation of the pruritic nails from
the nail beds)
- Vaginal mucosa - Thick white curdy discharge (cottage cheese-like), severe itching,
dysuria, vaginal itching, pain with sex, redness around the vagina; Penis- itch or rashes
Vaginal mucosa
*Dx Test: Wet Mount (vaginal smear or wet prep– gram straining) test
results: hyphae, budding yeast
* RF: HIV, DM, Pregnancy, Stress, and AntiBiotic treatment
* TREATMENT: antifungal suppository (MICONAZOLE) @ HS for 1 week
Oral antifungal --- Fluconazole (DIFLUCAN) –for systemic
infection, vaginal infection(SINGLE DOSE)
--- Nystatin – for oral thrush
Injectable --- Amphotericin – for life-threatening fungal I
nfections
*** Fetus may contact thrush during delivery/
treatment of baby with oral Nystatin 1cc q6h

*HEALTH TEACHING: Yugort in diet ; no douching ; cotton underwear

BACTERIAL VAGINOSIS (BV) (GARDNERELLA
VAGINALIS) (VAGINITIS)
* Overgrowth of bacteria naturally found in the vagina (normal
vaginal flora); Transmitted through sexual contact; loss of
protective lactobacilli bacteria
* RF: Douching, new or multiple sex partners, antibiotics,
using an intrauterine device
* S/Sx: thin-watery vaginal discharge with fishy odor
(vaginal ph >5)
* Dx Test: Whiff test (performed by adding a small
amount of potassium hydroxide to a microscopic
slide containing the vaginal discharge)
* TREATMENT: FLAGYL (Metronidazole 500mg
BID X 7 days)
*** Risk for PTL and PROM
TRICHOMONIASIS (“trich”) (TRICHOMONAS VAGINALIS)
* a very common STD/STI caused by protozoan parasite
Trichomonas Vaginalis
* S/Sx: thin-greenish-yellow foamy or frothy foul smelling
vaginal discharge in women and no symptoms in men,
itching in the genital area, burning with urination,
pain with sex
* Dx Test: Microbiological culture
or microbial culture
* TREATMENT: METRONIDAZOLE
(safe in pregnancy)
*** Risk for PTL and PROM
CHLAMYDIA
* caused by Bacterium Chlamydia Trachomatis/ THE MOST COMMON STD
* can cause PID and infertility by blocking the tubes
* S/Sx: Often Asymptomatic; Thin-purulent discharge; Burning &
frequency with Urination; lower Abd’l. pain; Painful sexual intercourse
(dyspareunia)
***chlamydia cannot be
* Dx test: Nucleic acid amplification tests (NAAT), spread through casual
Enzyme-linked immunosorbent assay (ELISA) contact such as kissing,
hugging, or sharing baths,
* TREATMENT: AZITHROMYCIN 1g single dose (safe for pregnants); towels, swimming pools,
DOXYCYCLINE 2 caps a day for 1 week toilet seats, or cutlery.
* COMPLICATIONS: NB Conjunctivitis (ERYTROMYCIN ointment)
Neonatal Pneumonia
PTL/ Fetal death
*** Perinatal transmission occurs in 50% infants where mom is
infected @ time of delivery
GONORRHEA
* a bacterial STI caused by Neisseria Gonorrhea; can lead to PID> Infertility
* often asymptomatic in females with Green-Frothy discharge/ males have
burning sensation with urination and penile discharges
* Dx: Vaginal or urine culture (DOH notifies partners)
* Treatment: Rocephin IM (CEFTRIAXONE) or Zithromax (AZITHROMYCIN) 1 g SD
* S/Sx: patient manifests cramping, fever, chills, purulent discharge,
N/V, uterine swelling, adnexal & cervical tenderness
* multiple sex partners with no condoms should be treated also
>Drug of choice (DOC): DOXYCYCLINE p.o. (for non-preg.)
>DOC: ROCEPHIN IM, CLINDAMYCIN, GENTAMICIN (for preg.)---- may need
hospitalization
HERPES (Herpes Simplex Virus) (HSV)
* a viral infection, highly contagious
* HSV 1 – Oral Outer Lesion (COLD SORE)
* HSV 2 – Genital (Painful, open lesions)
* S/Sx: Blisters that break open and form small ulcers, fever, swollen
lymph nodes (Vesicles rupture & appear right appear exposure or
within 20 days),burning sensation with urination (1st sign)
* Tingling sensation occurs before new outbreak (Outbreaks several times/
year
* Dx: Viral culture test or Nucleic Acid Amplification test (NAT) of a sample
of skin, crust, or fluid from a lesion
* Treatment: ACYCLOVIR or VALTREX 500 mg OD/ during pregnancy
reduces viral load enough to deliver vaginally
SYPHILIS (Treponema Pallidum - Spirochete)
* a bacterial STI; Treponema pallidum is the causative agent
* Primary Stage: small painless sores “chancre” (1 cm and 2 cm in diameter) approx. 2-3 weeks initial exposure, fever, malaise
* Secondary Stage: 6 wks to 6 mos., a diffuse rash occurs, which frequently involves the palms of the hands and soles of the feet, there
may also be sores in the mouth or vagina
* Latent Stage: which can last for years, there are few or no symptoms
* Tertiary Stage: there are gummas (soft, non-cancerous growths), neurological problems, or heart symptoms
* Congenital Syphilis: transmitted during pregnancy or during birth (enlargement of the liver and spleen, rash, fever, neurosyphilis, and
lung inflammation
* Dx: venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) tests
* Treatment: <1 yr. 2.4 million units BENZATHINE Penicillin x 1 dose
>1 yr. same medication 1x/wk for 3 wks
* Sexual partners screened and treated/ D0C- CEFTRIAXONE (1ST Tri.)
* 40% chance of stillbirth or death; infant may be born with “Congenital Syphilis” or “Opthalmia Neonatorum” that causes blindness
(appears as conjunctivitis in newborn (NB))
* Give baby Penicillins (PCN) every day x 10 days

syphilitic gumma
GENITAL WARTS (Condyloma,Condylomata acuminata, venereal warts, anal warts, anogenital warts)

❖ Sexually transmitted infection caused by certain types of human

papillomavirus (HPV)
❖ It is spread through direct skin-to-skin contact, usually during oral,
genital, or anal sex with an infected partner
❖ Contact occurs during vaginal birth (infant may have laryngeal warts)
❖ Symptoms: Skin lesion that is generally pink in color and project outward
❖ Usual onset: 1-8 months following exposure
❖ Diagnostic method: Based on symptoms, can be confirmed by biopsy
❖ Prevention: HPV vaccine, condoms
❖ Treatment: Cryotherapy
TRICHLOROACETIC ACID
GARDASIL VACCINE (3 doses)
For all STI cases, seek
consultation from an
STI Specialist…
Preventing Sexually Transmitted Diseases (STDs)

 Consider that not having sex is the only sure way

to prevent STDs (abstain from all intimate
contact)
 Only Have Sex Within a Mutually Monogamous
Relationship
 Make All Sex Safer Sex
 Consider Vaccination
BLEEDING DISORDERS OF PREGNANCY
❖ First Trimester Bleeding
a. ABORTION
b. ECTOPIC PREGNANCY
❖ Second Trimester Bleeding
a. HYDATIDIFORM MOLE
b. INCOMPETENT CERVIX
❖ Third Trimester Bleeding
a. PLACENTIA PREVIA
b. ABRUPTIO PLACENTA
ABORTION- most common bleeding d/o of early pregnancy/
termination of pregnancy before viability (before 20 weeks)

ABORTUS – a fetus that is aborted before it is 500 g in weight

BLIGHTED OVUM – a small macerated fetus, sometimes there is

no fetus surrounded by a fluid inside the sac

MACERATION – a dead fetus undergoing necrosis

EARLY ABORTION – termination of pregnancy before 16 weeks

LATE ABORTION – abortion that occurs between 16 to 20 weeks

➢ FETAL CAUSES OF ABORTION:
* most common cause of early spontaneous abortion is abnormal
development of the zygote, embryo and fetus
* this abnormalities are incompatible with life and would have
resulted to severe congenital anomalies if pregnancy has not been
aborted

➢ MATERNAL CAUSES OF ABORTION

* congenital or acquired conditions of the mother & environmental
factor that had adversely affected the pregnancy outcome & led to
abortion (e.g. DM, INCOMPETENT CERVIX, exposure to Radiation
& Infection)
TYPES OF ABORTION:
Missed Abortion
Inevitable Abortion
Septic Abortion
Habitual Abortion
Threatened Abortion
Incomplete Abortion
Complete Abortion
MISSED ABORTION
* retention of all products of
conception after the death of
the fetus in the uterus
* no FHT
* signs of pregnancy disappear
INEVITABLE ABORTION
* the loss of the products of conception
cannot be prevented
* moderate to profuse bleeding, moderate
to severe uterine cramping
* open cervix
* rupture of membrane
➢SEPTIC ABORTION
* abortion complicated by
infection
* foul smelling vaginal discharge
* uterine cramping
* fever
HABITUAL ABORTION
* abortion occurring in 3 or more
successive pregnancies
* the most common cause is a
significant genetic abnormality
of the conceptus
THREATENED ABORTION
* possible loss of product of
conception
* light vaginal bleeding
* none to mild uterine cramping
* vaginal exam. @ this stage
usually reveals a closed cervix
(25%- 50% results in loss of preg.)
INCOMPLETE ABORTION
* expulsion of some parts &
retention of other parts of
conceptus in uterus
* heavy vaginal bleeding/
severe uterine cramping/
open cervix/ passage of tissue
COMPLETE ABORTION
*spontaneous expulsion of the products
of conception after the fetus has died
in utero
* light bleeding/ mild uterine cramping/
passage of tissue/ closed cervix
NURSING RESPONSIBILITIES
Save all tissue passed (histopathology
exam.)
Strict bed rest (SBR) & monitor bleeding
Increased oral fluid or IV as ordered
Prepare client for surgical intervention
(D & C or suction evacuation) if needed
What is the priority Nursing Dx?