© 2016 Keith Rischer/www.KeithRN.com
Urinary Tract Infection/Urosepsis
Jean Kelly, 82 years old
Primary Concept
Infection
Interrelated Concepts (In
... [Show More] 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© 2016 Keith Rischer/www.KeithRN.com
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:
Increasingly worsening fatigue,
painful, burning, and frequent
urination
fever for 24 hours
weakness
confusion
Confusion is a common sign of UTI, and a change in mental
status should be evaluated.
Significant signs and symptoms of UTI prompting request
for UA
RELEVANT Data from Social History: Clinical Significance:
Lives independently in a retirement
community, wears a life alert button,
widowed and 2 daughters who active
and involved in her life.
The life alert button offers security and assistance to her in
case of an emergency when she is alone at home. She has
a strong support system from her daughters and can return
to a safe environment after discharge
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 1. Allopurinol 100 mg PO 1. Antipruritic
and antigout agents
2. Salicylates
3. Antidiabetic/
thiazolidinediones
4. Lipid -lowering
agents
5. Beta blockers
6. ACE inhibitors
7. Loop diuretics
8. Mineral & Electrolyte
replacements/suppl.
1. Lowering of serum
uric acid levels.
2. Reduce platelet
aggregation
3. Decrease insulin
resistance
4. Decrease
cholesterol/lipid levels
5. Decrease BP
6. Decrease BP
7. Diuresis/Decrease
BP
8. Prevention/
Correction of K
depletion
Hyperlipidemia bid
Hypertension (HTN) 2. ASA 81 mg PO daily
Gout 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
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 dominoesPatient 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:
Pulse: 110
Temperature: 101.8 F
BP: 102/50
Orthostatic hypotension
Resp. rate: 24
achycardia - the heart is overworking trying to
compensate Systemic sign of infection; indication of fever
The heart is beating fast to maintain pressure with
blood volume with combination of HR, also can be an
indication of fluid volume deficitSystolic change b/w supine and
standing
Tachypnea – indication of compensation
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:
Mental changes:
disorientation, and dizziness
Dysuria, frequency of
urination, and right flank
pain and tenderness with
palpitation
Oral mucosa: dry
BP changes with orthostatic hypotension, changing
position, dizziness, and not knowing of time, and place.
Classic signs and symptoms of UTI, flank pain and
tenderness with palpation which indicates the
involvement of the kidneys and signs of infection
Clinical sign of dehydration or fluid volume deficitRadiology 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
No resp issues
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
Neutrophils
Band forms
Indicates infection and Hgb
likely to rule out from
traumatic blood loss
contributing to fluid volume
deficit
A slight change from the
previous lab drawn can be due
to reactive thrombocytosis
Sign of infection and the body
is trying to fight off the existing
infection
Similar to neutrophils, which
can be an indicator of infection
or at risk of infection
WBC worsening and Hg is
stable
Stable
Worsening
Stable but can worsen
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
Elevated BUN
and Creatinine
Diabetes Type II – likely is
responding to the stress of
illness and temp. with
increased insulin demands
Indication of the dysfunction of
kidney which means the
kidneys are not producing
WORSEurine and filtering effectively
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 Indicates sepsis due to
hypoperfusion of the kidneys,
cell death due to anaerobic
metabolism - considered a
critical value of greater than 2
WORSE
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 Neg
Ketones (neg) Neg Neg
Bilirubin (neg) Neg Neg
Blood (neg) Neg Neg
Nitrite (neg) Pos Pos
LET (Leukocyte Esterase) (neg) Pos Pos
MICRO:
RBC’s (<5) 1 ABNL 0
WBC’s (<5) >100 ABNL 3
Bacteria (neg) LARGE Few
Epithelial (neg) Few Few
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Cloudy urine
Elevated
specific gravity
Protein in urine
Nitrites,
leukocyte
esterase, WBC,
bacterial &
epithelial
Sign of infection
Increased concentration of
urine due to fluid volume
deficit
Present in Type II Diabetes &
UTI Indicative of UTI; nitrites
indicate presence of bacteria,
LET and WBC indicate the WBC
trying to fight & attack the
infection.
ALL WORSE
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
Lactate
Value:
3.2
Critical Value:
2
Lactate is a
major sign of
sepsis
demonstrating
hypoperfusion of
systemic organs
Notify provider of critical value. Assess
vital signs: HR, BP, and temp. Perform
sepsis screen and notify sepsis team.
Enact orders as prescribed: fluid
replacement, cultures, and administer
broad spectrum antibiotics.Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
Creatinine
Value:
1.5
Critical Value:
Greater than
2 to 2.5
Indicative of
kidney function,
elevated
creatinine levels
signify
dysfunction of
the kidneys and
are not able to
effectively filtrate
Strict I/O, monitor urine characteristics,
and quality. Administer fluids, and
assess ability to urinate
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting?
2. What is the underlying cause/pathophysiology of this primary problem?Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
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
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
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
Ceftriaxone 1g
IVPB
50 ml
Hourly rate IVPB:
Collaborative Care: Nursing
3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY)4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
6. What is the worst possible/most likely complication to anticipate?
7. What nursing assessment(s) will you need to initiate to identify this complication EARLY if it develops?
8. What nursing interventions will you initiate if this complication develops?
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?
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 airCurrent 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:
Temp: 101.4F
Pulse: 116
BP: 98/50
HR: 22
Febrile but a decrease from previous temp. Worsening BP
and still demonstrating HR and resp. rate, however O2
stat is WNL
RELEVANT Assessment Data: Clinical Significance:
Cool, mottled extremities,
no urine output, and
disoriented
No urine output is a sign of worsening sepsis and renal
deterioration. The nurse should notify the provider
immediately. Mottled extremities and cool skin is a sign of
decrease cardiac output, unable to meet the demands and
trying to compensate due to fluid volume deficit.
1. Has the status improved or not as expected to this point?
Status has worsened and the provider should be contacted for additional orders to provide
more hemodynamic stability to support the patient and to preserve organ functions.
2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
The RN needs to notify the provider, plan of care should continue by providing hemodynamic
stability
3. Based on your current evaluation, what are your nursing priorities and plan of care? Nursing priorities
are: maintain hemodynamic stability by monitoring vital signs, urine output, I/O, administer antibiotics and
fluids, monitoring for signs of complications such as MODS, and
the patient may need Dobutamine.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 secondary to UTI. Administered 1L fluid bolus and 1 G
ceftriaxone. BP is not improving and no urine output
Background:
History of Type II Diabetes, Hyperlipidemia, and HTN. Admitted after 3 days of UTI symptoms and
acutely altered mental status and has respond to initial orders, BP, HR, urine out, respiration rate
continue to deteriorate
Assessment:
Cool, mottled extremities, fever at 101.4F, BP: 92/50, pulse: 116, oriented to self but not to time
or place. Oral mucosa: dry and tacky. Oliguric over the last two hours.
Recommendation:
Patient requires additional support, more fluid bolus recommended and if hemodynamic stability
is not achieved then Dobutamine may be needed
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? Improved
2. What data supports this evaluation assessment? 200 mL of urine output, elevation in BP, pulse: WNL,
temperature lowered and
decreased resp. 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, 82 yrs. old
BRIEF summary of primary problem: admitted for sepsis secondary to UTI.
Administered 1L fluid bolus and 1G ceftriaxone. BP is not improving and no urine
output
Day of admission/post-op #: Today
Background:
Primary problem/diagnosis: sepsis
secondary to urinary tract infection
RELEVANT past medical history:
Type II Diabetes, Hyperlipidemia, and
HTN.
RELEVANT background data: Admitted after 3 days of UTI symptoms and acutely
altered mental status and has respond to initial orders, BP, HR, urine out, respiration
rate continue to deteriorate.
Assessment:
Most recent vital signs: Temperature: 100.6F (oral), BP: 114/64, MAP: 81, pulse: 92, RR:
20, O2 stat: 98% on room air.
RELEVANT body system nursing assessment data: GU: 200mL; cloudy urine in Foley bag,
mottled, oriented to self but not to time or place. Oral mucosa: dry and tacky, cool
and mottled extremities.
RELEVANT lab values: WBC: 13.2, neutrophils: 93, band forms: 2, glucose: 184, BUN:
35, creatinine: 1.5, and lactate: 3.2, specific gravity: 1.032, protein, nitrites, leukocyte
esterase are present in urine, cloudy urine.How have you advanced the plan of care? 2 large boluses of 0.9% NS and inserted Foley
catheter
Patient response: patient has definitely improved, 200 mL of urine output, elevation in
BP, pulse: WNL, temperature lowered and decreased resp. rate.
INTERPRETATION of current clinical status (stable/unstable/worsening): STABLE
Recommendation:
Suggestions to advance plan of care: Continue to monitor patient and may require
additional support, and if hemodynamic stability is not achieved then Dobutamine
may be needed.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 area front to back and wear cotton underwear, avoid bath
tubs, increase fluid intake to promote renal blood flow and to flush bacteria from the urinary tract, adhere to
the antibiotic regiment prescribed by the provider, encourage frequent voiding every 2 to 3
hours to empty the bladder completely in which can lower urine bacterial counts, reduce
urinary stasis,and prevent reinfection. Avoid urinary irritants such as coffee, tea, colas, and
alcohol. Provide the patient with information about s/sx that they will need to notify the
provide
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? The
RN can assess the effectiveness of teaching with this patient by setting goals together, allowing to demonstrate
how to promote the proper perineal hygiene, test the patient’s knowledge of the condition, use simple terms
when communicating with patient, making sure the patient understand the medication as you administer, and
making sure the patient understand how and when to refill medications, ask the patient to tell you how they
would
explain the condition or treatment to someone
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
The patient might feel anxious, overwhelmed, and concerned of the condition and wants to
know is the plan of their care while they are in the hospital and how they can avoid or prevent
the condition.
2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as
a person?
You can engage with the patient by making sure that they understand the treatment plan, by
including family member, consider the patient’s limitations and strengths, and determine the
patient’s learning style.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? Alot
2. How can I use what has been learned from this scenario to improve patient care in the future? SO much [Show Less]