UTI urosepsis case study week 10 clinical,100% CORRECT

UTI urosepsis case study week 10 clinical Urinary Tract Infection/Urosepsis Jean Kelly, 82 years old Primary Concept Infection Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Fluid and Electrolyte Balance 3. Thermoregulation 4. Clinical Judgment 5. Patient Education 6. Communication UNFOLDING Reasoning Case Study: STUDENT History of Present Problem: Sepsis Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Personal/Social History: Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: Fever in last 24 hours Fatigue and weakness Burning sensation when urinating, increased frequency of urinating Confusion Infection Generally not feeling well Rule out UTI Rule out UTI RELEVANT Data from Social History: Clinical Significance: Has family in town Lives independently good support system Independent woman, still able to perform self-care What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: Diabetes type 2 Hyperlipidemia Hypertension (HTN) Gout 1. Allopurinol 100 mg PO bid 2. ASA 81 mg PO daily 3. Pioglitazone 15 mg PO daily 4. Simvastatin 20 mg PO daily 5. Metoprolol 25 mg PO bid 6. Lisinopril 10 mg PO daily 7. Furosemide 20 mg PO daily 8. Potassium chloride 20 mEq PO daily 1. xanthine oxidase inhibitors 2. salicylates 3. thiazolidinediones 4. hmg coa reductase inhibitors 5. beta blocker 6. ace inhibitor 7. loop diuretic 8. mineral and electrolyte replacements/supplements 1. Decreased serum and urinary uric acid levels. 2. Prevention of MI. 3. Control of blood glucose levels. 4. Decrease in LDL and total cholesterol levels. 5. decrease in BP 6. decrease in BP 7. decrease in edema & BP 8. Prevention and correction of serum potassium depletion. One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life? • Circle what PMH problem started FIRST • Underline what PMH problem(s) FOLLOWED as dominoes Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 101.8 F/38.8 C (oral) Provoking/Palliative: Nothing/Nothing P: 110 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Right flank BP: 102/50 Severity: 5/10 O2 sat: 98% room air Timing: Continuous The nurse recognizes the need to validate his/her concern of fluid volume deficit and performs a set of orthostatic VS and obtains the following: Position: HR: BP: Supine 110 102/50 Standing 132 92/42 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Temperature is high Fever, indicates infection Respirations are high respiratory compensating for metabolic status (acidosis) Pulse is high systemic response to stress Changes in BP when laying to standing orthostatic hypotension, fall precautions Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm and dry, no edema, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented x2-is not consistently oriented to date and place, c/o dizziness when she sits up GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Dysuria and frequency of urination persists, right flank tenderness to gentle palpation SKIN: Skin integrity intact, lips dry, oral mucosa tacky dry What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Neuro is abnormal GU is abnormal Skin is abnormal patient is confused w/o having a hx of confusion this is a vague, uncommon symptom of UTI, especially with elderly. She is feeling dizzy when she stands because of the orthostatic hypotension Flank pain can indicate kidney infection or pyelonephritis. Urinary frequency is common symptom of UTI Oral mucosa should be moist, lips shouldn’t be dry, patient is likely dehydrated. Radiology Reports: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Results: Clinical Significance: No infiltrates or other It is a good sign that the patient’s lungs are clear, that means she isn’t experiencing abnormalities. No pneumonia. We can rule out that pneumonia is not causing her septic symptoms. changes from last previous Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC): Current: High/Low/WNL? Previous: WBC (4.5-11.0 mm 3) 13.2 High 8.8 Hgb (12-16 g/dL) 14.4 Wnl 14.6 Platelets (150-450x 103/µl) 246 Wnl 140 Neutrophil % (42-72) 93 High 68 Band forms (3-5%) 2 low 1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC is high Neutrophils is high Indicates infection – immune response Indicates infection – immune response, likely bacterial infection Worsening Worsening Basic Metabolic Panel (BMP): Current: High/Low/WNL? Previous: Sodium (135-145 mEq/L) 140 Wnl 138 Potassium (3.5-5.0 mEq/L) 3.8 Wnl 3.9 Glucose (70-110 mg/dL) 184 High 128 BUN (7 - 25 mg/dl) 35 High 14 Creatinine (0.6-1.2 mg/dL) 1.5 high 1.1 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Glucose is high BUN is high Creatinine is high When there is an infection in a person with DM then glucose levels are harder to manage Indicates pt is dehydrated, also elevated because kidneys aren’t functioning well Kidney aren’t functioning well, possible AKI, will need to monitor kidney function especially when on antibiotics. Pharmacy to dose abx. Worsening Worsening Worsening Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6-2.0 mEq/L) 1.8 wnl 1.9 Lactate (0.5-2.2 mmol/L) 3.2 high n/a RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Lactate level is high Lactate levels are commonly evaluated in acutely ill pt, most commonly in context of evaluating shock. Can indicate hypoperfusion of cells. No previous point of reference. Urine Analysis (UA): Current: ABNL/WNL? Previous: Color (yellow) Yellow Wnl Yellow Clarity (clear) Cloudy abnl Clear Specific Gravity (1.015-1.030) 1.032 Abnl 1.010 Protein (neg) 2+ Abnl 1+ Glucose (neg) Neg Wnl Neg Ketones (neg) Neg Wnl Neg Bilirubin (neg) Neg Wnl Neg Blood (neg) Neg Wnl Neg Nitrite (neg) Pos Abnl Pos LET (Leukocyte Esterase) (neg) Pos Abnl Pos MICRO: RBC’s (5) 1 Wnl 0 WBC’s (5) 100 Abnl 3 Bacteria (neg) LARGE Abnl Few Epithelial (neg) Few Abnl Few RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Clarity: cloudy Specific gravity: 1.032 Protein: 2+ WBC’s: 100 Nitrate: positive Leukocyte esterase: positive Bacteria: Large This finding usually consistent with infection. Dehydration, confirms volume depletion Large protein molecules getting filtered through the glomeruli could indicate renal disease, especially with hx of DM WBC’s present reflects positive UTI Byproduct of gram negative bacteria, most common culprit is women E. Coli Detects the prescense of the enzyme esterase release by leukocytes, would expect this to be positive if there is WBC present in the micro UA. Confirms other markers, there is a presence of infection. Worsening Worsening Worsening Worsening Worsening Worsening Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Lactate Value: 3.2 2 Critical Value: 5 Key indicator for sepsis and anaerobic metabolism. Lactate is byproduct of anaerobic metabolism in shock states, due to decreased oxygenation anaerobic metabolism increase. BIG RED FLAG if increasing. Monitor BP and HR closely for concerning trends Assess for hypotension with known infection, this could mean septic shock Assess closely for change in temperature trend. Hypothermia or febrile can both represent sepsis especially in elderly. Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Creatinine Value: 1.5 0.5-1.3 Critical Value: 1.5 Kidney function is compromised Elevated when lack of perfusion to the kidneys due to distributive shock such as sepsis Assess for fluid retention/edema Daily weight Monitor I&O Monitor labs Pharmacy to dose antibiotics – or try to use antibiotics that are metabolized more so by the liver. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? UTI - Sepsis/urosepsis with dehydration (hypovolemia) 2. What is the underlying cause/pathophysiology of this primary problem? Urinary tract infections are amongst the most common bacterial infections. They can occur in either an uncomplicated host setting, where there is no underlying structural or functional abnormality of the patient's genitourinary tract or complicated, where there is (foreign body, Foley Catheter, obstruction, retention). Bacteria vary widely in their ability to successfully invade the urinary tract; the vast majority of such infections being due to a small number of species. The route is usually ascension from the urethra. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV Patient is very ill and will need IV fluids and medication, won’t be able to administer without IV access Able to establish PIV and start fluids right away. 0.9% NS 1000 mL IV bolus Fluid resuscitation is needed as this pt is in a volume depleted state secondary to the inflammation process Improve fluid volume, revive BP, decrease heart rate. Acetaminophen 650 mg Promote patient comfort and lower fever Decrease in temperature. Ceftriaxone 1g IVPB…after blood/urine cultures obtained Cephalosporin binds to bacterial cell wall, causing cellular death. Broad-spectrum and less damaging on kidneys than other abx. Resolution of infection after completed course. Morphine 2 mg IV push every 2 hours prn-pain Opiod which will alter the perception and response to painful stimuli, produces generalized CNS depression Pain level decreased PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: • Establish peripheral IV • 0.9% NS 1000 mL IV bolus • Acetaminophen 650 mg • Ceftriaxone 1g IVPB… after blood/urine cultures obtained • Morphine 2 mg IV push every 2 hours prn-pain 1. Establish peripheral IV 2. 0.9% NS 1000mL IV bolus 3. Ceftriaxone 1g IVPB…after blood/urine cultures obtained 4. Morphine 2 mg IV push every 2 hours prn-pain 5. Acetaminophen 650 mg 1. IV access is needed to complete some of these orders 2. Low BP and need for IV fluid resuscitation 3. Need to attack bacteria that are causing the infection 4. Pain control is always a high priority that needs to be addressed 5. Fever reduction - antipyretic Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Ceftriaxone 1g IVPB 3rd generation cephalosporin binds to bacterial cell wall causing cellular death 50 ml/30 mins Hourly rate IVPB:100 ml/hr Obtain blood cultures and urine cultures before starting antibiotics. Ask about allergies and observe pt for reaction from infusion of abx. Anaphylactic reaction- rash, wheezing, laryngeal edema, itching. Stop infusion and follow protocol. Collaborative Care: Nursing 3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY) The nursing priority that should be always come first is patient safety and ABC’s. In the care of this patient we need to get cultures done ASAP so we can start providing life saving treatment. I will also start an IV and fluids to address the C in ABC. Bringing this full circle is safety, and she will need to be on fall precautions due to the risk of falling. 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Establish peripheral IV with 18-20 gauge Reassess VS q 15 mins during and after IV bolus Assess mental status because of confusion symptom Risk for falls interventions like close and frequent observation, bed alarm Needs IV for isotonic fluids as bolus and IV antibiotics administered To determine how effective the treatment has been Watch carefully as a general reflection of overall status Alert the nurses if patient is trying to get out of bed so one can go and assist pt IV established and fluids started HR decrease, BP increase Mental status improves w/ resolution of infection Patient safety is #1, pt will remain free from falls. 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? GU- this is the main system causing the problems, need to make sure patient gets antibiotics to treat infection and get relief from all the symptoms like flank pain and urinary frequency. Assess urine output as marker for renal perfusion. Cardiac- Need to get perfusion to all organs and extremities, increase fluid volume. 6. What is the worst possible/most likely complication to anticipate? Septic shock, multiple organ dysfunction syndrome 7. What nursing assessment(s) will you need to initiate to identify this complication EARLY if it develops? Assessing VS to see if they are improving. Frequent monitoring q 30 mins to an hour. SIRS criteria. 8. What nursing interventions will you initiate if this complication develops? Increase perfusion by giving crystalloids or colloid solutions and vasopressors like norepinephrine to constrict blood vessels and get BP back, get MAP 65mmHg. Oxygenate patient, possible mechanical ventilation. Fight microorganism, abx therapy. Decrease system-wide inflammation, start low dose corticosteroids, protein activated C. Early nutrition, helps with GI integrity, give enteral nutrition. Control blood glucose to 180, insulin drip. 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? CDC reports that 1 in 3 patients who die in the hospital have sepsis, that is a very concerning number. Septic shock is a very serious problem and it can end in death. The family will be very distraught and worried. 10. How can the nurse address these psychosocial needs? I would keep them informed of everything being done and reassure them that every measure will be taken to save the patient. I would be available to the family for them to voice concerns and ask questions. Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two Hours Later… Current VS: Most Recent: T: 101.4 F/38.6 C (oral) T: 101.8 F/38.8 C (oral) P: 116 (regular) P: 110 (regular) R: 22 (regular) R: 24 (regular) BP: 98/50 BP: 102/50 O2 sat: 98% room air O2 sat: 98% room air Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Color flushed. Skin is warm and dry centrally, but upper/lower extremities are mottled in appearance and cool to touch, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented x2-is not consistently oriented to date and place GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: No urine output the past two hours. SKIN: Skin integrity intact 1. What clinical data are RELEVANT and must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: T: 101.4 F/38.6 C (oral) P: 116 (regular) R: 22 (regular) BP: 98/50 Temp went down, but this is 2 hours later, and I would’ve wanted to see it come down more after having acetaminophen and antibiotics already. Will continue to closely monitor trend. Pulse went up, we are not moving in the right direction, there is still vasodilation happening and body is continuing to elevate HR to maintain cardiac output. Will follow protocol and notify doc of the progress. Monitor closely, Respirations are still fast but at least came down a couple. Continue to monitor this VS along with O2 sat closely. BP is falling from the last measurement taken 2 hours ago, another sign that we are doing in the wrong direction. I would call doc and report the progress, get further instructions. RELEVANT Assessment Data: Clinical Significance: Cardiac: Color flushed. Skin is warm and dry centrally, but upper/lower extremities are mottled in appearance and cool to touch, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post- tibial landmarks GU: No urine output in the past 2 hours. There is significant change to this body system that what was examined 2 hours ago. Extremities are now cool to touch, that is a giant red flag, this sepsis case is progressing to septic shock. We have at least the pulses are strong and equal with palpation, but the skin color and temperature are not good. Doctor will definitely be called immediately with report. Normal urine output for adult is 30 ml/hr, this proves worsening sepsis, and this is a sign that kidneys are not being perfused, possible organ system failure. Will be reported when calling the doctor. 1. Has the status improved or not as expected to this point? The patient status has worsened, and this is not what we would’ve hoped for. As healthcare providers I think we always want things to get better, we want to save lives, we have faith that we can fix it, we are open to miracles. I think if any healthcare provider loses hope and doesn’t work hard to make the impossible happen anymore then they have become jaded and need a change of pace. So yeah this outcome that has presented itself progressed itself even with the interventions we made. At this point I would be check the code status so I know what I should do if that occurs. 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? My nursing priority at this time would be to call and update the physician. The need to know all of these assessment findings to give additional orders. I would recommend to push more fluids and admit patient to ICU for closer monitoring. 3. Based on your current evaluation, what are your nursing priorities and plan of care? Continue to closely monitor patient and give report to the doctor. VS q 30 min-1 hr. Follow whatever doc’s orders are after I give SBAR. Because you have not seen the level of improvement you were expecting in the medical interventions, you decide to update the physician and give the following SBAR: Situation: 82 year old female, positive UTI, and urosepsis Background: This is an update for physician, so they already know this part. Assessment: After 1L fluids of 0.9% NaCl and dose of abx there is no improvement in condition. Pulse & BP are getting worse T: 101.4 F/38.6 C (oral), P: 116 (regular), R: 22 (regular), BP: 98/50. Upper/lower extremities are mottled in appearance and cool to touch, no urine output in last 2 hours. Recommendation: Give another bolus and transfer to ICU. The physician agrees with your concerns and decides to repeat the 0.9% NS bolus of 1000 mL and insertion of Foley catheter. After one hour this has completed and you obtain the following set of VS: Current VS: Most Recent: T: 100.6 F/38.1 C (oral) T: 101.4 F/38.6 C (oral) P: 92 (regular) P: 116 (regular) R: 20 (regular) R: 22 (regular) BP: 114/64 MAP: 81 BP: 94/48 MAP: 63 O2 sat: 98% room air O2 sat: 98% room air Current Assessment: GU: 200 mL cloudy urine in bag 1. Has the status of the patient improved or not as expected to this point? Yes, the patient status has improved tremendously. Almost all VS are wnl, just the temperature is still a little high, but the body is fighting an infection, and its still early on. It is amazing what some fluid in the pipes can do! 2. What data supports this evaluation assessment? All vital signs are trending in the right direction and there is urine output before there wasn’t. Your patient, who is still in the emergency department, is now being transferred to the intensive care unit (ICU) for close monitoring and assessment. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: Jean Kelly, female, 82 yo BRIEF summary of primary problem: Pt brought to the ED by daughter. Pt reports feeling fatigued past few days and a fever that started yesterday. Pt states she experienced painful burning sensation when urinating and urinating more than normal for last week. Pt daughter expressed concern about mother seeming to be confused, didn’t know what day it was. No past hx of confusion. Day of admission/post-op #: N/A, pt is being admitted now, not related to previous surgery. Background: Primary problem/diagnosis: positive UTI, urosepsis Relevant past medical history: hypertension, DM type II Relevant background data: lives alone, independent, has good support system in family. Assessment: Most recent vital signs: T 101.8, P 110, R 24, BP 128/82, O2 98% RA Relevant body system nursing assessment data: GU has urine output 200 mL just recently, pt has Foley catheter in place. Relevant lab values: WBC 13.2, neutrophils 93%, Creatinine: 1.5, Lactate 3.2, UA positive for UTI. How have you advanced the plan of care: Patient received 2 separate bolus of 0.9% NS and cetrixaone 1 g IVPB administered. Patient response: After first bolus the HR increased and BP dropped, also no urine output, but doctor notified. Doc ordered another bolus and insert Foley. Interpretation of current clinical status (stable/unstable/worsening): pt is getting better. Stable at this moment, but in very fragile state. Recommendation: Suggestions to advance plan of care: Monitor very closely and check VS often. Prevent progression of sepsis. Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with Jean’s medical condition to prevent future readmission with the same problem? I would give Jean education about preventing UTI. She should make sure she is wiping from front to back, even though I would assume an 82 year old woman has her routine in wiping by now, it’s important to reiterate. Because maybe she is having issues wiping from front to back, also make sure she wipes enough, so where there isn’t any wetness leftover. I would also encourage pt to shower instead of bath. Another important part would be to increase fluid intake, that will keep pt hydrated, kidneys flushed, and urine clean and clear. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? Understand of the teaching session can be assessed by asking the patient to repeat back to me what they learned. At this time I can see where there are any gaps that need to be bridged and I can reiterate those important key points. Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient is likely feeling better now, they aren’t as sick as they were when they first arrived, they have a diagnosis and are on the mend. I would be feeling pretty good right now if I were the pt, despite my condition, at least I can be rest assured that I’m in a good place, getting great treatment, not wasting away at home getting worse. I’m sure I’m still feeling pretty crappy inside and things are exactly right and back to normal but I would have hope that they will be soon. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? I always intend to incorporate Mother Theresa’s (I mean Jean Watson’s) Caritas when I practice nursing. I will be open to letting miracles happen, and have faith for the members in my community. I will attend to the patient basic needs first and move up the hierarchy as seen fit. The patient deserves the best care possible, as I would hope that when I’m in that situation, I’m given the best care possible. I always treat others with respect, kindness, and consideration. I will communicate therapeutically and actively listen to pt. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? I learned a lot about UTI and urosepsis and about all aspects of how to care for these patients with those conditions. I learned lessons about their nursing care like what signs and symptoms to look for and monitor closely, especially pay careful attention to trends in the data. I know what kind of interventions to take to treat sepsis and how to prevent septic shock. Like giving fluid bolus and administering abx. 2. How can I use what has been learned from this scenario to improve patient care in the future? In the future I know more about what to expect with patient coming in with similar symptoms and how to handle their care. I will use everything I learned, what I just stated in previous questions, to provide excellent, quality care. References for this case study