Comprehensive Care Plan for a Patient with Multiple Infections

QUESTION

I need help with the turn it in score to be less than 30% on this case study, it is currently at 90%.

 

Patient Initials _HH_ 

Subjective Data: Ms. HH, a 28-year-old female, presents herself to the clinic today with complaints of frequency, burning, and pain when urinating x 2 days. She also is experiencing increased abdominal pain that she reports is now severe in the lower abdomen/pelvic area. She reports she has had foul-smelling, brown discharge accompanied by abdominal pain since her last unprotected intercourse with her previous partner 14 days ago.

Chief Compliant: “I have had problems peeing in the past 2 days. It is painful and burns and I feel like I must urinate constantly. I also have pain in my lower stomach and have had a brown, smelly vagina discharge since I last had sex with my ex-boyfriend.”

History of Present Illness- Ms. HH states that she has urinary tract infections often (three occurrences this past year that were treated appropriately). She also reports that she was treated for gonorrhea twice and chlamydia once. She has had a total of four pregnancies and has birthed three children.

PMH/Medical/Surgical History: Patient reports she is allergic to trimethoprim/sulfamethoxazole (Bactrim) (rash) and does not take any prescription or over-the-counter medications currently. She denies any history of severe acute or chronic illnesses. She reports the only previous surgery she has had is a bilateral tubal ligation in 2017. She states that her last pap smear was 6 months ago.

Significant Family History: Patient denies any serious medical conditions of family members.

Social History– Patient denies the use of alcohol and street drugs and states she has never smoked. Patient reports she now lives with her new male significant other and her three children. The patient admits to having multiple male sexual partners within recent months.

Review of Symptoms: 

Review of Systems

General: Positive for feeling moderately distressed.

Integumentary- Denies any bruising, lesions, rashes, or abrasions.

Head- WNL.

Eyes: WNL.

ENT: WNL.

Cardiovascular: Denies chest pain and palpitations.

Respiratory: Bilateral lung sounds clear, denies shortness of breath, coughing, or wheezing.

Gastrointestinal: Denies nausea/vomiting/diarrhea. Positive for severe pain in lower abdomen/pelvic region. Denies alterations in eating and bowel habits.

Genitourinary: Positive for frequency, urgency, and burning when urinating. Positive for brown, foul-smelling vaginal discharge.

Musculoskeletal: Denies change in extremities, denies joint swelling and tenderness.

Neurological: WNL

Endocrine: WNL

Hematologic: Denies abnormal bleeding, denies bruising

Psychologic: Denies mood alteration

Objective Data: 

Vital Signs: BP -100/80 P ;80 R ;16 T ;99.7

Wt-120. ; Ht-5’0. ; BMI-23.4

 

Physical Assessment Findings:

Lymph Nodes: Intact, no enlarged nodules

Carotids: No jugular vein distention or bruits noted.

Lungs: Clear bilaterally

Heart: Regular rhythm/rate with S1 and S2 noted. Absence of murmur of a gallop.

Abdomen: Soft and nondistended. Bowel sounds present x 4 quadrants. Tenderness and pain on palpitation in suprapubic region.

Genital/Pelvic: Adnexal and cervical motion tenderness. Brown vaginal discharge with a foul odor

Rectum: WNL

Extremities/Pulses: Pulses in all extremities are strong and equal bilaterally

Neurologic: WNL

 

Laboratory and Diagnostic Test Results: 

Leukocyte differential:

Neutrophils- 68%

Bands-7%

Lymphocytes-13%

Monocytes-8%

Eosinophils- 2%

 

Urinalysis results:

Color- Pale straw

Specific gravity- 1.015

PH- 8.0

Protein- negative

Glucose- negative

Ketones- negative

Bacteria- many

Leukocytes- 10-15

Red blood cells- 0-1

 

Urine gram stain reveals gram-negative rods. Vaginal discharge culture reveals gram-negative diplococci and Neisseria gonorrhoeae- sensitivities are pending. Positive results for Chlamydia trachomatis monoclonal antibodies. Negative KOH and VDRL test. The vaginal smear is negative.

 

Assessment: 

1. Gonococcal female pelvic inflammatory disease (ICD-10 code: A54.24)
2. Chlamydial female pelvic inflammatory disease (ICD-10 code: A56.11)
3. Urinary tract infection, site unspecified (ICD-10 code: A56.00)

Plan of Care:

Gonococcal female pelvic inflammatory disease (A54.24)

Education- She will need education on healthy and safe sexual practices. Sexually transmitted diseases are a leading cause of women developing Pelvic Inflammatory Disease (PID). PID may cause scarring and genital tract dysfunction, resulting in infertility, chronic pelvic pain, and ectopic pregnancy (Reekie et al., 2018). This patient should be educated on the possible consequences of not getting recurrent STIs. Other education topics for this patient include proper hygiene practices. Frequent douching can change the pH balance of the vagina and alter its normal flora, allowing enteric bacteria to recolonize the vagina (Dains et al., 2019). This can contribute to vaginal discharge. Any material used during sexual intercourse, such as diaphragms or sexual toys may also need to be disinfected (Dains et al., 2019). The patient’s partner should also be tested for STIs as well as they can continue to pass infections back and forth if both are not treated.

Goals- Medical intervention is necessary to clear the infection and prevent further damage to the reproductive organs. This may include antibiotics, as well as other medications to reduce inflammation. PID can be a very emotionally traumatic experience due to pain and discomfort, as well as the fear of infertility. Providing emotional and psychological support to help the patient cope is very important. Lifestyle changes may need to be made to help prevent PID. These include avoiding douching, using condoms during sexual activity, and avoiding sexual activity if there is an active infection.

Therapeutic management- Depending on the severity of the problem, a patient with PID will get a different course of therapy. Antibiotics are a treatment option for PID that is mild. Often used are, metronidazole, ceftriaxone, and doxycycline. They are prescribed for 7 to 10 days. After completion of the antibiotics, if symptoms do not improve, the patient may be hospitalized. The patient will receive intravenous antibiotics and be constantly watched. Surgery could be required to remove any abscesses or scar tissue that has developed.

Evaluation- Follow-up appointments should be scheduled 3 days after starting therapy so that the doctor may assess how well the antibiotics are working. If they appear to be working, the patient may be scheduled for a follow-up to determine if the therapy was successful. More tests or hospitalization may occur if treatment did not work. Make sure that any sexual partner the patient had in the last 6 months has been tested to prevent recurrent infection. Patients should refrain from having sex until both partners have finished therapy.

Chlamydia pelvic inflammatory disease (A56.11)

 Education- Make sure the patient knows to notify if they are pregnant as certain antibiotics should not be used during pregnancy. Antibiotics can cure chlamydia. The patient’s sex partner should also be treated so the infection doesn’t spread. Call the doctor if you have new abdomen or pelvic pain, have a fever, have new or increased burning pain with urination, or have pain, swelling, or tenderness in the scrotum. Also notify if you have unusual vaginal bleeding, discharge from the vagina or penis, exposure to another STI, symptoms get worse, or no improvement after 1 week of starting treatment.

Goals- The goal of treating Chlamydia is to make sure the patient is adherent to their medication regimen. Take antibiotics as prescribed for the entire treatment. Preventing spread by abstaining while being treated and notifying all sexual partners so they may be treated as well.

Therapeutic Management- The preferred treatment for Chlamydia is a single dose of azithromycin or doxycycline for 7 days. For Doxycycline, avoid unnecessary sunlight exposure, and do not take it with antacids, iron products, or dairy. Not permitted in pregnant women.

Evaluation- Keeping follow-up appointments is key for the proper treatment of Chlamydia. Notifying the provider of any new or persisting symptoms is important. Making sure the patient notifies all sexual partners to be tested and treated to prevent the spread of infection.

Urinary tract infection, site unspecified (A56.00)

Education- Prevention of UTI education should be stressed to the patient. Lifestyle behavioral modifications should be provided. Drinking plenty of water, frequent urination, wiping from front to back, avoiding soaking in the bathtub, and avoiding tight-fitting underwear. Make sure to explain the importance of completing antibiotic therapy, even if the symptoms improve. Urinating and washing immediately after sexual intercourse can also reduce the chance of UTI reoccurrence (Vecchio, Iroz, & Seksek, 2018).

  Goals- Goals for this patient include making and keeping follow-up appointments. Making sure the patient knows and understands prevention methods. Finishing antibiotics even if symptoms improve is key.

Therapeutic management- Ceftriaxone has an antibiotic susceptibility of E. coli at 94.7% (Kang et al., 2018). Setting up a urine culture with sensitivity could be important since she has many infections present in her body at the same time. If it showed resistance to any of her current antibiotic prescriptions, she may need another single antibiotic that is susceptible to the bacteria.

Evaluation- This patient really needs to keep follow-up appointments with all the infections present. She needs to complete all antibiotic therapies and maybe have another urine test completed to see if the treatment worked. Monitoring for changes in worsening symptoms and reporting in a timely manner is important for proper treatment.

ANSWER

Comprehensive Care Plan for a Patient with Multiple Infections

Introduction

This essay presents a comprehensive care plan for Ms. HH, a 28-year-old female with multiple infections, including gonococcal and chlamydial pelvic inflammatory disease (PID), as well as an unspecified urinary tract infection (UTI). The plan addresses education, therapeutic management, goals, and evaluation for each condition, considering evidence-based practices and patient-centered care.

Gonococcal Female Pelvic Inflammatory Disease (PID) (A54.24)

Education
Ms. HH will receive education on safe sexual practices, the consequences of recurrent STIs, and proper hygiene. Partner testing and disinfection of materials used during intercourse will be emphasized.

Goals
Clear the infection and prevent further damage to reproductive organs.
Provide emotional and psychological support to help cope with pain and discomfort.
Lifestyle changes to prevent PID, including avoiding douching and using condoms.

Therapeutic Management
Mild PID: Antibiotics (e.g., metronidazole, ceftriaxone, doxycycline) for 7-10 days.
Severe PID: Hospitalization, intravenous antibiotics, surgical intervention if necessary.

Evaluation
Follow-up appointments at 3 days to assess antibiotic effectiveness.
Partner testing and treatment.
Abstain from sex until both partners complete therapy.

Chlamydia Female PID (A56.11)

Education
Educate Ms. HH on notifying pregnancy, adhering to antibiotic regimen, partner treatment, and notifying a healthcare provider about symptoms.

Goals
Ensure medication adherence.
Prevent spread by abstaining from sex while being treated.
Notify sexual partners for testing and treatment.

Therapeutic Management
Single dose of azithromycin or doxycycline for 7 days.

Evaluation:
Follow-up appointments.
Partner testing and treatment.

Urinary Tract Infection (UTI) (A56.00)

Education
Emphasize prevention methods: drinking water, frequent urination, proper hygiene, completing antibiotic therapy, urinating after intercourse.

Goals
Attend follow-up appointments.
Understand prevention methods.
Complete antibiotics even if symptoms improve.

Therapeutic Management
Ceftriaxone with urine culture and sensitivity.

Evaluation
Follow-up appointments.
Complete antibiotic therapy.
Monitor and report worsening symptoms.

Conclusion

This comprehensive care plan for Ms. HH addresses her multiple infections through education, therapeutic management, goal setting, and evaluation. Patient education on safe practices, medication adherence, and preventive measures is essential for successful treatment and prevention of future infections. Close monitoring and follow-up appointments ensure optimal outcomes and patient well-being. By tailoring the plan to evidence-based practices and Ms. HH’s individual needs, a patient-centered approach is achieved, promoting effective and holistic care.