Urinary Tract Infection/Urosepsis
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
1. Perfusion
2. Fluid and Electrolyte
... [Show More] 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
setng
© 2016 Keith Rischer/www.KeithRN.com2. How can I use what has been learned from this scenario to improve patient care in the future?
The skills gained from completing this case scenario are critical for my future practice. The case has helped me
become a fast thinker and a problem solver, the skills that I did not initially possess. I have felt like I was
practicing the skills in a healthcare facility
References
Dreger, N. M., Degener, S., Ahmad-Nejad, P., Wöbker, G., & Roth, S. (2015). Urosepsis—etiology, diagnosis,
and treatment. Deutsches Ärzteblatt International, 112(49), 837.
Kalra, O. P., & Raizada, A. (2009). Approach to a patient with urosepsis. Journal of Global Infectious
Diseases, 1(1), 57.
Nutz, P. A., & Albanese, J. A. (2016). Mosby's Nursing Drug Cards E-Book. Elsevier Health Sciences.
Wagenlehner, F. M., Lichtenstern, C., Rolfes, C., Mayer, K., Uhle, F., Weidner, W., & Weigand, M. A. (2013).
Diagnosis and management for urosepsis. International Journal of Urology, 20(10), 963-970.
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