BENGALURU
PERFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
Ms. BEENA ANN THOMAS
M. Sc NURSING 1ST YEAR,
MEDICAL SURGICAL NURSING,
2010 - 2011 BATCH.
R.R COLLEGE OF NURSING,
RAJA REDDY LAYOUT,
CHIKKABANAVARA,
BENGALURU-560090.
RAJIV GANDHI UNVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Ms. BEENA ANN THOMAS
1ST YEAR M. Sc NURSING,
R.R COLLEGE OF NURSING,
RAJA REDDY LAYOUT,
CHIKKABANAVARA,
BENGALURU- 560090.
2. / NAME OF THE INSTITUTION / R.R College of Nursing
3. / COURSE OF THE STUDY AND SUBJECT / Master’s Degree of Nursing,
Medical Surgical Nursing.
4. / DATE OF ADMISSION TO THE COURSE / 25/01/2010
5. / TITTLE OF THE STUDY / A study to evaluate the effectiveness of structured teaching program on prevention of urinary tract infection among diabetes mellitus clients in selected hospitals, Bengaluru.
6. BRIEF RESUME OF INTENDED WORK
6.1 Introduction
“You can’t do anything about the length of your life. But you can do something about its width and depth” EVEN ESSAR
Happiness is nothing more than good health. Urinary tract infections are caused by pathogenic microorganism in the tract. It is the second most common reason clients seek health care (Porth 2005).1
The urinary tract, from the kidneys to the urethral meatus, is normally sterile and resistant to bacterial colonization despite frequent contamination of the distal urethra with colonic bacteria. Mechanisms that maintain the tract's sterility include urine acidity, emptying of the bladder at maturation, ureterovesical and urethral sphincters, and various immunologic and mucosal barriers.2
Urinary tract infections (UTIs) are more common and tend to have a more complicated course in patients with diabetes mellitus than in the general population. The mechanisms that potentially contribute to the increased prevalence of both asymptomatic and symptomatic bacteriuria in these patients are defects in the local urinary cytokine secretions and an increased adherence of the microorganisms to the uroepithelial cells. There are several reasons for an increased frequency of UTIs in diabetic patients. Several aspects of immunity are altered in patients with diabetes
Diabetes mellitus is a chronic medical condition which means it can last a life-time. According to the World Health Organization, India had 32 million diabetic subjects in the year 2000 and this number would increase to 80 million by the year 2030.The International Diabetes Federation (IDF) Also reported that the total number of diabetes subjects in India was 41 million in 2006 and that this would rise to 70 million by the year 2025. Diabetes Mellitus is predicted to become the leading cause of morbidity and death in the coming decade. India has a high prevalence of diabetes mellitus and numbers are increasing at an alarming rate. Health care workers have more responsibility to create awareness regarding diabetes mellitus and other complications this disease causes the individuals. 3
Diabetes mellitus is the most common endocrine disease and is associated with organ complications due to microvascular and macrovascular disease. People with diabetes also suffer from simple and complicated infections, Anatomical Spectrum of Infection states that UTIs invariably enter via the ascending route. Asymptomatic bacteriuria has been reported to be commoner in women with diabetes, although less common among men. Type II diabetes is a common condition, affecting 2% to 3% of the adult population, and up to 20% to 25% of the elderly population.
6.2 NEED FOR STUDY
Urinary tract infections are a serious health problem affecting millions of people each year.
Infections of the urinary tract are the second most common type of infection in the body. Urinary tract infections (UTIs) account for about 8.3 million doctor visits each year. Women are especially prone to UTIs for reasons that are not yet well understood. One woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very serious when they do occur.
In diabetes mellitus, overwhelming infection can predispose to pyogenic infection with intrarenal perinephric abscess formation, emphysematous pyelonephritis, and, very rarely, a specific form of infective interstitial nephropathy. Papillary necrosis is a common consequence of pyelonephritis in diabetics. Females are more prone to asymptomatic bacteriuria than diabetic men, but in both sexes progression to clinical pyelonephritis are more likely than in normal individuals. The risk factors for developing asymptomatic bacteriuria differ between type I and type II diabetes.
People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary infection.
Top of Form
A study conducted by A.Ronalda E.Ludwigb and they reported that in adults diabetes, Urinary tract (UTI) is a major disease burden for many patients with diabetes. Asymptomatic bacteriuria is several-fold more common among women and acute plyelonephritis is five to ten times more common in both sexes. The complications of pyelonephritis are also more common in patients with diabetes. These complications include acute papillary necrosis, emphysematous pyelonephritis, and bacteremia with metastatic localization to other sites. The management of urinary infection in patients with diabetes is essentially the same as patients without diabetes. Most infections should be managed as uncomplicated except when they occur in a milieu with obstruction or other factors that merit a diagnosis of complicated UTI. Strategies to prevent these infections and reduce morbidity should be a priority for research.4
Urinary tract infections (UTIs) are a common burden in patients with diabetes mellitus. Cystitis, ascending infections leading to pyelonephritis, emphysematous complications and renal and perinephric abscesses are well recognized in the group of patients especially if glycaemic control is poor. Despite the clinical significance of UTI in diabetes, it is inadequately understood and management regimens are mostly not evidence based. Anticipation of potential complications and earlier interventions are vital to reduce serious adverse outcomes.
UTIs fall into both these categories i.e. exclusive and more severe. Asymptomatic bacteriuria, acute pyelonephritis and complications of UTI are reported to be more common in patients with diabetes. Bacteraemia is four times more likely to occur from UTIs in patients with diabetes than in non-diabetic clients. Acute renal failure is twice as likely to develop in bacteraemic patients
Urinary tract infections (UTIs) are more common and tend to have a more complicated course in patients with diabetes mellitus than in the general population. Diabetes has significant associated morbidity. Prevention and treatment of the complications of diabetes mellitus have the potential to improve quality of life and increase life expectancy.
Prevention of urinary tract infection in the compromised host represents the most efficacious management when significant bacterial colonization is likely. Assessing the degree of inflammatory response helps to tailor the antimicrobial therapy in both acute and chronic bacterial infestation. Therefore, frequent urine cultures and urinalysis in high-risk patients should assist the attending physician to avoid the high cost of morbidity and mortality.5
The investigator felt that it is very essential to educate the Diabetic clients regarding prevention of urinary tract infection. This will improve the clients ‘s knowledge, quality of life and adopting simple solutions.
6.3 REVIEW OF LITRATURE
St. Boniface General Hospital, University of Manitoba conducted A study is conducted on Urinary tract infections in adults with diabetes. Urinary tract (UTI) is a major disease burden for many patients with diabetes. Asymptomatic bacteriuria is several-fold more common among women and acute plyelonephritis is five to ten times more common in both sexes. The complications of pyelonephritis are also more common in patients with diabetes. These complications include acute papillary necrosis, emphysematous pyelonephritis, and bacteremia with metastatic localization to other sites. The management of urinary infection in patients with diabetes is essentially the same as patients without diabetes. Most infections should be managed as uncomplicated except when they occur in a milieu with obstruction or other factors that merit a diagnosis of complicated UTI. Strategies to prevent these infections and reduce morbidity should be a priority for research.
Department of Endocrinology, China PLA General Hospital, Beijing, conducted A study was conducted onurinary tract infection with diabetes mellitus and related factors. The results of urine culture between the mid-urine and the bladder puncture urine in 30 cases of diabetes mellitus. The results showed that female elderly NIDDM and the patients with diabetic retinopathy, nephropathy and neuropathy had higher incidence of urinary infections. When the leukocyte count in routine urine examination was more than 10 increases/HP, the incidence of urinary infection was higher. The urine culture with bladder puncture was more reliable than mid-urine. The nursing care for prevention of the urinary infection in diabetes was also discussed.
Anna Cantagallo conducted a study on Cost-Free Prevention to Asymptomatic Bacteriuria in Diabetes to analyze asymptomatic bacteriuria as a complication in diabetic women. It is known that urinary tract infections (UTIs) are an important problem in diabetic individuals, and bacteriuria is more common in diabetic women than in nondiabetic women and because of several factors that predispose diabetic individuals to infection. Several studies confirm that there is a higher prevalence of ASB in diabetic women than in non-diabetic women. The result showed Asymptomatic Bacteriuria was found in 79 of the 148 patients with alterations of glucose values; all 79 patients were postmenopausal and 69 patients had type 2 diabetes (age 58 ± 14.9 years), and the other 10 had type 1 diabetes (age 47.3 ± 7.4 years); all of the patients suffered from habitual UTIs or ASB. Escherichia coli was the most frequently isolated microorganism (42 patients [53%]). In addition, Klebsiella oxytoca was found in 18 patients (22.7%), Enterobacter cloacae was found in 12 patients (15.1%), and Proteus mirabilis was found in 7 patients (8.8%). ASB disappeared after successful treatment with specific antibiotics. They also investigated on hygiene habits of the 79 patients with ASB, showed 68 patients used one hand and one towel to wash and dry both the genital and anal regions. The remaining 11 patients used both hands to wash, one for the genital and one for the anal region, but only one towel to dry the two different regions. The anatomical characteristics of women may facilitate the migration of intestinal microorganisms in the urinary tract. Some subjects that are 68 patients change their habits and use both hands and two different towels to wash and dry the two different regions. After 6 months of these hygiene modifications, they repeated the midstream urine analysis and found that only 16 (20.2%) of the 79 patients had ASB. E. coli remained the most frequently isolated microorganism, with 11 cases (68.7%); Klebsiella oxitoca was found in 3 of the 16 patients (18.7%), and Enterobacter cloacae was present in 2 cases (12.5%). None of the patients had ASB caused by Proteus mirabilis. They concluded stating careful hygiene habits in diabetic women could present an easy and cost-free way to help prevent ASB. 6
Asymptomatic bacteriuria may be considered a complication in women with diabetes. Diabetes Mellitus Women Asymptomatic Bacteriuria Utrecht Study Group.The study was conducted on the prevalence of and risk factors for asymptomatic bacteriuria (ASB) in women with and without diabetes. A total of 636 non-pregnant women with diabetes (type 1 and type 2) who were 18-75 years of age and had no abnormalities of the urinary tract, and 153 women without diabetes who were visiting the eye and trauma outpatient clinic (control subjects) were included. They define ASB as the presence of at least 10(5) colony-forming units/ml of 1 or 2 bacterial species in a culture of clean-voided midstream urine from an individual without symptoms of a urinary tract infection (UTI). The result showed, the prevalence of ASB was 26% in the diabetic women and 6% in the control subjects (P < 0.001). The prevalence of ASB in women with type 1 diabetes was 21%. Risk factors for ASB in type 1 diabetic women included a longer duration of diabetes, peripheral neuropathy, and macroalbuminuria. The prevalence of ASB was 29% in women with type 2 diabetes. Risk factors for ASB in type 2 diabetic women included age, macroalbuminuria, a lower BMI, and a UTI during the previous year. They concluded stating that the prevalence of ASB is increased in women with diabetes and might be added to the list of diabetic complications in these women.7
Pozzilli P,Leslie R Department of Diabetes and Metabolism, St. Bartholomew's Hospital, London, UK ,conducted a study on Infections and diabetes: mechanisms and prospects for prevention ,infections remain a serious hazard for the diabetic patient. Good metabolic control is a major factor in limiting the development and spread of infections and, most importantly, the development of diabetic complications which predispose to infections. In some patients recurrent infections can pose a problem, particularly if there is evidence of secondary immunodeficiency. In these patients, adjuvant therapies, including Biological Responses Modifiers should be considered. Several factors could predispose diabetic patients to infections. These factors include: genetic susceptibility to infection; altered cellular and humoral immune defense mechanisms; local factors including poor blood supply and nerve damage, and alterations in metabolism associated with diabetes. In the context of a diabetic patient all or some of these factors may operate. The purpose of this review is to assess the relative contribution of these potential mechanisms in leading to infection in patients with diabetes.8
Lye WC, Chan RK, Lee EJ, Kumarasinghe G, Division of Nephrology, National University, conducted a study to determine whether there is any difference in the bacteriological pattern of UTI and the antibiotic sensitivity patterns of the pathogens concerned between diabetic and non-diabetic patients. Over a period of 1 year, a total of 287 diabetic patients (221 females and 66 males) with community-acquired and nosocomial urinary tract infections were studied. There were 265 patients (228 females and 37 males) without any predisposition to urinary tract infections (UTI) and who served as controls. Although Escherichia coli were the predominant organism in community-acquired UTI in diabetic patients, it was found significantly less than in the non-diabetic population (P less than 0.005). The percentage of Klebsiella species causing community-acquired UTI in diabetic patients was significantly higher than in non-diabetics (P less than 0.005).
Urinary tract infections in patients with diabetes.
Epidemiologic studies suggest that bacteriuria and urinary tract infection (UTI) occur more commonly in women with diabetes than in women without this disease. Similar findings have been demonstrated for asymptomatic bacteriuria (ASB), with ASB being a risk factor for pyelonephritis and subsequent decline in renal function. Although ASB is not associated with serious health outcomes in healthy patients.. Patients with diabetes often have increased complications of UTI, including such rare complications as emphysematous cystitis and pyelonephritis, fungal infections (particularly Candida species), and increased severity and unusual manifestations (e.g., gram-negative pathogens other than Escherichia coli). Anatomic and functional abnormalities of the urinary tract are also associated with diabetes. Such abnormalities result in greater instrumentation of the urinary tract, thereby increasing the risk of secondary UTI. In addition, these abnormalities complicate UTI and require specialized treatment strategies. There is a greater likelihood of UTI affected by antimicrobial resistance or atypical uropathogens, and the risk of upper tract involvement is increased. Pre- and post therapy urine cultures are therefore indicated. The initial choice of empiric antimicrobial therapy should be based on Gram stain and urine culture. Choice of antibiotic therapy should integrate local sensitivity patterns of the infecting organism. Fluoroquinolones are a reasonable empiric choice for many patients with diabetes. For seriously ill patients, including patients infected with Pseudomonas spp., such agents as imipenem, ticarcillin-clavulanate, and piperacillin-tazobactam may also be considered. Treatment of ASB in patients with diabetes is often recommended to prevent the risk of symptomatic UTI. However, the management of ASB in patients with diabetes is complex.9
A study conducted by University of Texas Science Centre at San Antonio, USA Reported that Bacterial UTIs are a common problem in patients with diabetes mellitus. Bacteriuria is more common in diabetic women than in non-diabetics owing to a combination of host and local risk factors. Upper tract disease is also more common in this group. Diabetics are at higher risk for intrarenal abscess, with a spectrum of disease ranging from acute focal bacterial pyelonephritis to renal corticomedullary abscess to the renal carbuncle. A number of uncommon complicated UTIs, such as emphysematous pyelonephritis and emphysematous pyelitis, occur more frequently in diabetics. Because of the frequency and severity of UTI in diabetics, prompt diagnosis and early therapy is warranted.10
M Banadio, C Gigil, A Vigne conducted a study on urinary tract infection in diabetes clients ,the aim of study was to compare the epidemiological, microbiological and clinical features of diabetic patients with urinary tract to those of non-diabetes one. They did a prospective study on 490 consecutive patients with proven urinary tract infection ,the patient were studied on the basis of a specific questionnaire and hospital records .The results showed 89(18.1%) had diabetes mellitus and most frequent causative agents of UTI in diabetes and non-diabetes were E-Coli (56.8%),Proteus sp.(7.2%),Pseudomonas sp.(8.2%), Entrococcus sp.(7.2%).Both diabetes (52.8%) and non-diabetes (42.2%) had recurrent UTI during the follow –up period.11
Kathleen A Head, MD conducted a study on Peri and Post menopausal women / diabetes, A cohort study done on 1,017 menopausal women followed for 2years during which 138 UTI occurs significant risk factors included diabetes treated with insulin and having a history of six or more previous UTI’s. The relationship between diabetes and risk for UTI was further examined in a group of post menopausal women age 55-75.The result showed that UTI incidence was 12.2 per 100 person year in the diabetes group and 6-7 in the non-diabetes group.