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Unfolding Clinical Reasoning Case Study edited Urinary Tract Infection/Urosepsis Jean Kelly, 82 years old

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Unfolding Clinical Reasoning Case Study edited Urinary Tract Infection/Urosepsis Jean Kelly, 82 years old Urinary Tract Infection/Urosepsis Primary Concept Infection Interr... elated 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 Sepsis History of Present Problem: 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. © 2016 Keith Rischer/www.KeithRN.com Jean Kelly, 82 years oldPersonal/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: Progressive fatigue and fever Frequent urination, a painful and burning sensation during urination Acute confusion with no history of confusion Clinically significant symptoms of inflammation or infection Clinical manifestations for urinary tract infection (UTI) create a need to order urinalysis (Wagenlehner et al.,2015). Confusion is common among older people with UTI, creating a need to investigate a need to examine psychological status changes (Wagenlehner et al.,2015). RELEVANT Data from Social History: Clinical Significance: She lives in a senior apartment for the retirement community. She has two daughters who are concerned about her well-being. She wears an alert button. She has a healthy support system and will be safe upon being discharged from the hospital. The alert button is an effective safety tool during emergencies, hence calling for help as she lives independently. 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 inhibitor 2. Salicylate 3. Thiazolidinedione 4. Statin 5. Beta-blocker 1. Reduce uric acid production to prevent gout attacks 2. Stop the secretion of natural substances that stimulate inflammation, fever, pain, and blood clotting. © 2016 Keith Rischer/www.KeithRN.com6. Angiotensin-converting enzyme (ACE) inhibitor 7. Loop Diuretic 8. Electrolyte 3. Control blood glucose level 4. Reduce cholesterol levels 5. Reduce heart rate, the strain of the heart muscles, and blood pressure 6. Reduces blood pressure 7. Boost potassium level lost through diuresis (Nutz, & Albanese, 2016). 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 Diabetes Type 2 • Underline what PMH problem(s) FOLLOWED as dominoes Hypertension, Hyperlipidemia, Gout 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 © 2016 Keith Rischer/www.KeithRN.comThe 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: T:101.8F/38.8 P:110 R:24 BP:102/50 Orthostatic hypotension A high temperature is a clinically significant sign of fever and infection sepsis. A high pulse rate is clinically significant for reduced cardiac output and increased compensatory response by the heart (Dreger et al.,2015) The heart beats fast to maintain the pressure that results from a decrease in the blood volume. Increased respiration rate indicates that the shock is no longer compensatory but progressive, creating a need for immediate intervention. High HR also suggests a decrease in fluid volume (Dreger et al.,2015). Changes in Orthostatic BP is a clinical indicator for reduced fluid volume; tachypnea indicates compensation (Dreger et al.,2015) 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: Inconsistency in orientation; c/o dizziness Dysuria, frequent urination, Orthostatic BP changes explain why the patient experiences dizziness upon sitting upright. Her orientation to time and pace is inconsistent, creating a need to investigate UTI symptoms (Dreger et al.,2015). Sensitivity to pain upon palpitation is a clinically significant indicator © 2016 Keith Rischer/www.KeithRN.comsensitivity to pain upon gentle palpitation Lips and oral mucosa tacky dry of kidney, urethra, and bladder infection. A clinically significant indicator of fluid volume deficit. 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 abnormalities. No changes from last previous Chest radiography is clinically significant for detecting any chest abnormalities. From the results, the patient had no chest abnormalities. 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 and Hgb Platelets High WBC and normal Hgb is a clinically significant infection symptom and helps rule out the differential diagnosis caused by blood loss and fluid deficit (Dreger et al.,2015). Platelets are WNL but rose higher compared to the previous draw. This is a clinically significant indicator of an infection. Thrombocytosis is a condition that results from an elevated level of platelets due to an infection (Dreger et WBC worsening Hgb stable Stable © 2016 Keith Rischer/www.KeithRN.comNeutrophil Band forms al.,2015). An elevated level of neutrophil is a clinically significant infection sign since the body secrets more neutrophil in response to a prevailing infection (Dreger et al.,2015). They are considered neutrophils in their early stages, and a change in count indicates the presence or the risk of infection (Dreger et al.,2015). Worsening Improve 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 Increase in BUN and creatinine The patient has diabetes type 2, and her body may be reacting to the illness and fever, therefore, creating a high demand for insulin (Dreger et al.,2015) These demonstrate the functioning of the kidney, and an elevated level is a clinically significant indicator for kidney malfunctioning, that is, there is inadequate urine filtration/production in the kidney (Dreger et al.,2015) 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: © 2016 Keith Rischer/www.KeithRN.comLactate Clinically significant indicators for sepsis result from kidney hypoperfusion and cell death due to anaerobic metabolism. It is considered critical if the value is greater than 2. (Dreger et al.,2015). Worsening 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: Cloudy urine Increase in specific gravity Protein in urine Nitrites, leucocytes, WBC, bacteria, and epithelial Indicates presence of an infection Indicates an increase in urine concentration as a result of deficient fluid volume A clinically significant symptom for type 2 diabetes and UTI Clinically significant UTI indicators; Nitrites indicate bacteria presence, leucocytes, and WBC indicates WBC reaction to an infection (Dreger et al.,2015). Worsening Worsening Worsening Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: © 2016 Keith Rischer/www.KeithRN.comLactate Value: 3.2 Critical Value: 2 Lactate is a clinically significant symptom of sepsis and demonstrates hypoperfusion of systemic organs (Dreger et al.,2015).  Inform the provider about the critical value.  Assess the patient's vital signs, including the HR, BP, and temperatures (Dreger et al.,2015).  Conduct a sepsis screening and notify the sepsis interdisciplinary team (Dreger et al.,2015)  Administer the orders as indicated by the physician, including fluid replacement, antibiotics, and blood culture (Dreger et al.,2015) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Creatinine Value: 1.5 Critical Value: Greater than 2 to 2.5 Creatinine is a clinically significant indicator of kidney functioning. Elevated levels indicate that the kidney is not functioning correctly, and urine production/filtration is ineffective (Wagenlehner et al.,2015).  Monitor the characteristics and the quality of urine  Strict I & O  Fluid therapy  Determine the patient’s ability to urinate  The patient may need foley for incontinence, and strict I &O. Check the hospital policy to determine the foley criteria (Dreger et al.,2015) Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? The patient initially developed UTI. However, the clinical symptoms indicate that the signs and symptoms have progressed to a systemic level indicating sepsis. 2. What is the underlying cause/pathophysiology of this primary problem? The underlying cause may be untreated UTI, which has progressed to the urethra and bladder, resulting in kidney dysfunction. The clinical implication is systemic sepsis. "Severe sepsis is defined as a systematic inflammatory response related to infections such as pneumonia, with dysfunction or failure of one or more organs (e.g., renal insufficiency, ARDS or disseminated intravascular coagulation)" (Honan, pg. 305). Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV To access the circulatory system to begin IV access obtained to initiate © 2016 Keith Rischer/www.KeithRN.com0.9% 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 treatment (Wagenlehner et al.,2015). Fluid replacement enhances blood pressure and prevents dehydration (Wagenlehner et al.,2015). To reduce fever Broad-spectrum antibiotics Pain management (Wagenlehner et al.,2015). treatment Increase in blood pressure The temperature level will reduce The medication will alleviate the bacterial infection. The patient will report improvement and reduced pain levels. 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 2 5 3 4 Usually, venous access is obtained before initiating any form of treatment. Therefore this would be the top priority. The patient's low blood pressure requires immediate fluid administration to support the patient during treatment. Again, the treatment goal is to replace the lost fluid and maintain adequate tissue perfusion. Antibiotics therapy would be performed to fight the infection. Morphine would be administered for pain control and management. Acetaminophen is administered to lower the body temperature (Dreger et al.,2015) Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Ceftriaxone 1g IVPB Third-generation cephalosporin 50 ml  Check if the patient is allergic to penicillin or any © 2016 Keith Rischer/www.KeithRN.comantibiotic. It attaches to the bacterial cell membrane to stop the formation of a cell wall Hourly rate IVPB: 30 minutes form of cephalosporins.  Assess the patient’s history of antibiotics (Nuts and Albanese,2016).  The nurse should obtain blood culture before administering any form of medication (Nuts and Albanese,2016).  The nurse should consider the adverse effects of the medication, including, diarrhea, vaginal candidiasis, and stomach upset (Nuts and Albanese,2016).  The nurses should monitor any infection signs such as laryngeal edema, anaphylaxis, difficulties in breathing, and inform the doctor immediately (Nuts and Albanese,2016). Collaborative Care: Nursing 3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY)  Maintain sufficient hemodynamic stability  It is critical to frequently monitor the patient’s vitals, pulse rate and administer orders as instructed by the provider to prevent any complication or exacerbated sepsis/organ failure. The rationale for the interventions is because the patient has sepsis, hypotension and the labs demonstrate renal dysfunction (Kalra, and Raizada,2009). 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: © 2016 Keith Rischer/www.KeithRN.comClosely monitor the vitals, particularly the blood pressure, urine output, and heartbeat rate.. Antibiotics infusion Develop measures to reduce falls risk Assess any signs of organ dysfunction and continued instability Monitoring the vitals helps in determining the patient’s response to medication. The nurse should check the blood pressure after IV fluid administration and inform the provider of any adverse changes for support (Wagenlehner et al.,2015). The nurse should obtain blood cultures before and after administering antibiotics. The nurse should check if the patient has any allergies and closely determine any infusion reactions. Preventing infection and a response will ensure sufficient hemodynamic stability (Wagenlehner et al.,2015) Hemodynamic instability causes orthostatic hypotension. Therefore, the patient should not have slippery footwear. She should have a bed alarm and wear a fall risk bracelet (Wagenlehner et al.,2015) Sepsis and hemodynamic instability may cause MODS due to inadequate organ perfusion. Therefore, monitoring the patients I & O including the frequency of urination, kidney functioning and respiratory functions is critical to detect and take corrective action against any changes (Wagenlehner et al.,2015). The patient’s blood pressure will be normal and become stable after administration of the fluid bolus The patient will take the antibiotics without developing any complications The patient will not fall in the course of hospitalization The patient will be safe from organ failure due to complications. 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? © 2016 Keith Rischer/www.KeithRN.com Cardiovascular system; Closely monitor the blood pressure and the heart rate to establish the patient’s response to the interventions.  Renal system; Assess the urine output to determine the presence of an infection and the renal functioning amidst sepsis. 6. What is the worst possible/most likely complication to anticipate? The patient may develop multiple organ dysfunction MOD) as a complication of severe sepsis and organ hypoperfusion thus resulting to failure of the organs (Wagenlehner et al.,2015) 7. What nursing assessment(s) will you need to initiate to identify this complication EARLY if it develops? Assess the systemic organs through a comprehensive head-to-to examination. Assess the urine output, the kidney functioning and the patient’s response to treatment. Monitor the lung sounds, bowel sounds and breathing patterns. Monitor the heart rate, pattern, blood pressure and temperature. Consequently, administer acetaminophen and apply a cool towel to lower the patient’s temperature. Additionally, conduct a neuroexam to determine the patient’s mental well-being (Wagenlehner et al.,2015) 8. What nursing interventions will you initiate if this complication develops? Notify the doctor immediately, Fluid therapy; Administer oxygen as per the patient’s demand and monitor the vital signs. MODS is a critical condition that may require the nurse to place the patient under ventilation and provide vasopressors to maintain the blood pressure (Wagenlehner et al.,2015) 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Jean is lucky enough to have a strong family support and a safe residence. The nurse should constantly update Jean and her daughter about the condition and the pathophysiology of the disease in an easily understandable manner to alleviate anxiety. At the elderly age, it is critical for Jean to understand sepsis and its clinical manifestations and let her know that she should report to the doctor if she experiences any changes in her bowel. For instance, she should have reported to the doctor immediately she experienced pain during urination and frequent urination which occurred three days before reporting to the hospital. 10. How can the nurse address these psychosocial needs? The nurse may act as the case study manager and the educator for Jean and her family, explain the management plan and address any family or patient’s concerns and questions (Wagenlehner et al.,2015). © 2016 Keith Rischer/www.KeithRN.comEvaluation: 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:101.4F Pulse 116 BP 98/50 R:22 The patient is still febrile but has reduced from the previous recording. The patient still demonstrates tachycardia. The blood pressure is worsening, the patient still demonstrates tachypnea though oxygen is within the normal limits RELEVANT Assessment Data: Clinical Significance: NO URINE OUTPUT, cool, mottled extremities, disoriented NO URINE OUTPUT is a clinically significant symptom of severe sepsis and renal failure. Therefore, the nurse should report to the doctor immediately. Cool skin and mottled extremities are a clinical indicator for reduced heart output thus unable to meet the demands. © 2016 Keith Rischer/www.KeithRN.comTherefore, engaging in a compensatory state due to reduced fluid volume (Dreger et al.,2015) . 1. Has the status improved or not as expected to this point? The patient’s status has deteriorated and not as anticipated by this time. Therefore, the nurse should notify the doctor to provide alternative orders to maintain hemodynamic stability and enhance organ functioning. 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? The nurse should notify the provider. The plan of care remains the same as it is designed to promote hemodynamic stability for the patient (Dreger et al.,2015) 3. Based on your current evaluation, what are your nursing priorities and plan of care? The nursing priority is consistent which is to promote hemodynamic stability as dictated in the plan of care. The priority interventions include; monitoring the patient’s vitals, urine output, antibiotics and fluid therapy. Identifying any signs of complications including multiple organ dysfunction. At this point, the nurse may be required to provide the patient with a vasopressor to maintain the blood pressure (Dreger et al.,2015) . 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: Jean Kelly, Age 82, admitted for sepsis as a result of urinary tract infection (UTI). Has been administered with 1G ceftriaxone and IL fluid bolus. She demonstrates null improvements in her blood pressure and is now oliguric © 2016 Keith Rischer/www.KeithRN.comBackground: History of type diabetes type II, Hyperlipidemia and hypertension. She experienced pain during urination and frequent urination three days prior her admission. She has an altered mental status and has not responded to the initial orders. Her HR, BP and RR continue to worsen. Assessment: The patient has a cool skin, mottled extremities and a temperature at 101.4. Her last BP was 92/50 and a heart rate of 116.Her oral membranes are tacky and dry and has no urine output for the past two hours Recommendation: The patient requires additional support. She requires more fluid boluses and vasopressors incase on persistent hemodynamic instability. However fluid therapy is a priority. 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?  The patient has improved 2. What data supports this evaluation assessment? © 2016 Keith Rischer/www.KeithRN.com A urine output of 200ml, increase in Pulse rate within the normal limits, a decrease in temperature and respiratory rate. 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, age 82 BRIEF summary of primary problem: Admitted for sepsis secondary to UTI. Administered with 1G ceftriaxone and 1L fluid bolus. The patient shows no improvement in BP and is oliguric Day of admission/post-op #: Today Background: Primary problem/diagnosis: Sepsis secondary to UTI RELEVANT past medical history: Diabetes type 2, hyperlipidemia and hypertension RELEVANT background data: The patient experienced UTI symptoms three days prior the admission. Has an altered mental status. The patient did not respond to the initial orders. BP, Urine output and respiration rate are worsening Assessment: Most recent vital signs: Temperature 100.6(Oral); BP:114/64; P:92; MAP:81; O2 SAT:98% RELEVANT body system nursing assessment data: GU:200ml; cloudy urine in bag; Dry and tacky oral mucosa; disoriented to time and place; cool and mottled extremities © 2016 Keith Rischer/www.KeithRN.comRELEVANT lab values: WBC:13.2; Band forms:2; Glucose level:185; BUN:35; Lactate:3.2; Neutrophils:92; Creatinine;1.5: Specific gravity:1.032; Leukocyte esterase, protein and nitrites present in urine and cloudy urine How have you advanced the plan of care? 0.9%NS bolus of 1000ML and an inserted Foley catheter Patient response: The patient improved which was demonstrated by 200Ml urine output; Increase in blood pressure; A pulse rate within the normal limit; A decrease in temperature and respiratory rate INTERPRETATION of current clinical status (stable/unstable/worsening): Stable Recommendation: Suggestions to advance plan of care: Provide additional support for the patient and closely monitor the patient. A pressor may be needed if hemodynamic stability is achieved 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? Wash the perineal parts from back to front. Refrain from using bath tubs; Use cotton under wears. Optimum fluid intake to facilitate renal blood flow and to flush the bacteria from the urinary system. Inform the patient to adhere to the antibiotic medication administered by the physician. Inform the patient to void frequently, after every 2 to 3 hours to completely empty the bladder in order to reduce the bacteria count in the urine and prevent re-infection. Advise the patient to avoid urine contaminants such as alcohol, coffee, tea, and colas. Inform the patient about any warning signs and symptoms associated with UTI that they should report to the doctor immediately they experience (Dreger et al.,2015) 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? © 2016 Keith Rischer/www.KeithRN.comA nurse can assess the effectiveness education by setting goals with the patient and allowing her to demonstrate perineal hygiene. The nurse can use simple terms during education and ask the patient to repeat a procedure and ensuring the patient understands the medication, its use and when to refill. The nurse can apply teach back method and ask the patient to explain the condition and the treatment procedures involved Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient may feel overwhelmed, anxious and eager to know the care plan to treat her condition during hospitalization period. The patient may want to know how to prevent the condition from recurring. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? Engage the patient and ensure that she understands the care plan for her condition. Engage the family members during treatment. Determine the patient’s strengths and weaknesses and the learning approach that she can relate with. 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 have learned that urosepsis is a severe health complication that requires immediate interventions. Severe urosepsis may cause MODS and death. This scenario has improved my decision making and problemsolving skills under critcal situatons. The case has helped me relate with a real situaton in a clinical [Show More]

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