NR 341 Urosepsis Case Study Assignment

11 July 2024

NR 341 Urosepsis Case Study Assignment

Sepsis Sample 1

1. Important and relevant data from histories:

  • Clinical significance:

    • Patient age

    • Fatigue x3 days

    • Fever for x24 hrs

    • Painful, frequent, burning sensation with urination

    • Altered Mental Status (confusion)

    • Weakness

    • Elderly patients experience confusion more often with infections

    • Pain, urgency, and dysuria are common symptoms of UTI

    • Fever points towards infection

  • Clinical significance:

    • Patient is a widow but children help with ADLs

    • Lives independently

    • Lives alone but can call if help is needed

2. Relationship of past medical history and current meds:

  • Past medical history (PMH):
    • Diabetes type 2
    • Hyperlipidemia
    • Hypertension
    • Gout
  • Home meds:
    • Allopurinol 100mg PO bid
      • Pharm class: Xanthine oxidase inhibitors/anti-gout agents
      • Expected outcome: Lowers serum uric acid levels
    • ASA 81 mg PO daily
      • Pharm class: Salicylates
      • Expected outcome: Decreases likelihood of platelet aggregation
    • Pioglitazone 15 mg PO daily
      • Pharm class: Thiazolidinedione/antidiabetic
      • Expected outcome: Decreased insulin resistance
    • Simvastatin 20mg PO daily
      • Pharm class: HMG-CoA reductase inhibitor/lipid lowering agent
      • Expected outcome: Lowers total and LDL cholesterol
    • Metoprolol 25 mg PO bid
      • Pharm class: Beta blocker/antihypertensive
      • Expected outcome: Decrease BP
    • Lisinopril 10 mg PO daily
      • Pharm class: ACE inhibitors/antihypertensive
      • Expected outcome: Decrease BP
    • Furosemide 20 mg PO daily
      • Pharm class: Loop diuretic
      • Expected outcome: Diuresis of excess fluid
    • Potassium chloride 20 mEq PO daily
      • Pharm class: Electrolyte replacement
      • Expected outcome: Prevention of potassium depletion from the Lasix

3. Disease process likely developed FIRST:

  • Hyperlipidemia
    • Hypertension
    • Diabetes
    • Gout

1. Relevant VS data:

  • Temp: 101.8 F (high)
  • BP: 102/50 (low)
  • Orthostatic standing BP 92/42 low with 132 HR
  • Clinical significance:
    • Fever represents a sign of infection
    • Dehydration
    • Flank pain, chills, and fever indicate an infection involving the upper urinary tract (pyelonephritis)

2. Relevant assessment data:

  • A and O x2
  • Dizziness when sits up
  • Dysuria and frequency in urination
  • Right flank tenderness
  • Clinical significance:
    • Confusion in elderly is a sign of infection and an altered mental state is an atypical symptom of UTI but seen in elderly
    • Typical symptoms in UTI
    • Signs of dehydration

Radiology Report

Relevant diagnostic results:

  • Clinical significance:
    • Patient is not in respiratory distress

Lab Results

CBC:

  • WBC: 13.2 (high), previous 8.8
  • Hgb: 14.4 (WNL), previous 14.6
  • Platelets: 246 (WNL), previous 140
  • Neutrophil: 93 (WNL), previous 68
  • Clinical significance:
    • WBC: Indicates infection, worsening
    • Hgb: Can indicate anemia/bleed, improvement
    • Platelet: Indicates clotting factor, worsening
    • Neutrophil: Low puts pt at risk for infection, worsening
    • Band form: May help identify infection, stable

BMP:

  • Sodium: 140 (WNL), previous 138
  • Potassium: 3.8 (WNL), previous 3.9
  • Glucose: 184 (high), previous 128
  • BUN: 35 (high), previous 14
  • Creatinine: 1.5 (high norm), previous 1.1
  • Lactate: 3.2 (high), n/a
  • Clinical significance:
    • Glucose: Elevated for pt’s Diabetes and/or stress of being in hospital, worsening
    • BUN: Increased levels seen in dehydration and decreased levels seen in overhydration, worsening

UA:

  • Color: Yellow (WNL), previous Yellow
  • Clarity: Cloudy (ABNL), previous Clear
  • Specific Gravity: 1.032 (ABNL), previous 1.010
  • Protein: 2+ (ABNL), previous 1+
  • Glucose: Neg (WNL), previous Neg
  • Ketones: Neg (WNL), previous Neg
  • Bilirubin: Neg (WNL), previous Neg
  • Blood: Neg (WNL), previous Neg
  • Nitrite: Pos (ABNL), previous Pos
  • LET: Pos (ABNL), previous Pos
  • Clinical significance:

    • RBC’s: 1 (WNL), previous 0

    • WBC’s: >100 (ABNL), previous 3

    • Bacteria: LARGE (ABNL), previous Few

    • Epithelial: Few (ABNL), previous Few

    • Clarity: Cloudy urine may be caused by the presence of pus, RBCs, or bacteria, worsening

    • Specific Gravity: The specific gravity of the urine in a dehydrated patient can be expected to be abnormally high, worsening

    • Protein: If significant protein is noted at urinalysis, a 24-hour urine specimen should be collected to measure the quantity of protein, worsening

    • Nitrite: Positive Nitrite and LET both test indicate a urinary tract infection, worsening

    • LET: Positive Nitrite and LET both test indicate a urinary tract infection, worsening

    • WBC’s: Increased WBC’s indicates bacterial infection in the urinary tract, worsening

Lab planning

Creatinine:

  • Value: 1.5
  • Normal: 0.6-1.2
  • Critical: 1.5
  • Clinical significance: Illustrates the filtration capacity of the glomerulus, combined with BUN it illustrates kidney function
  • Nursing assessments/interventions required:
    • Educate patient to reduce protein intake
    • Increase fluid intake
    • Improve urinary tract health
    • Reduce blood pressure

Lactate:

  • Value: 3.2
  • Normal: 0.5 – 1.6
  • Critical: 3.2
  • Clinical significance: Ordered when signs of sepsis, shock, MI, severe CHF, kidney failure, or uncontrolled diabetes are present
  • Nursing assessments/interventions required:
    • Early recognition is key
    • Administer bicarb if related to metabolic acidosis
    • Monitor patient if also taking metformin for diabetes, especially in the case of poor kidney function
    • Correct dehydration (if applicable)

Primary problem and pathophysiology

Primary problem:

  • Urinary tract infection

Underlying cause/pathophysiology:

  • Bacterial contamination of the sterile urine usually occurs by retrograde movement of gram-negative bacilli into the urethra and bladder and then to the ureter and kidney. The infection causes an inflammatory response causing edema in the bladder wall, which brings on symptoms of bladder fullness with decreased volumes of urine and producing the urgency and frequency of urination associated with UTI.

Medical management

Care provider orders:

  • Establish peripheral IV
  • NS 1000 mL bolus
  • Acetaminophen 650 mg
  • Ceftriaxone 1g IVPB after blood and urine cultures obtained
  • Rationales:Expected outcomes:

    • IV access for fluids and antibiotics

    • Fluids for rehydration

    • Tylenol for temperature and pain

    • Antibiotic for UTI

    • Pain reliever

    • Better fluid balance and rehydration

    • Pain and fever reduced

    • Treat infection

Priority setting

Order of priority:

  • IV access
  • Blood and urine cultures
  • NS bolus
  • IVPB Ceftriaxone
  • Acetaminophen
  • Rationale:
    • IV access is the fastest way to rehydrate the patient and give medications
    • Obtain cultures (blood while getting IV access). Needs to be obtained before initiating antibiotic
    • NS bolus for hydration and decreased BP
    • Antibiotic started
    • Acetaminophen to decrease temperature
    • Morphine PRN

Medication dosage calculation

Ceftriaxone 1g IVPB:

  • Mechanism of action: Bind to the bacterial cell wall membrane, causing cell death
  • Volume/time frame to safely administer: 50 ml
  • Hourly rate IVPB: Obtain history of any reactions to penicillins or cephalosporins
  • Nursing assessment/consideration:
    • Observe for signs of anaphylaxis
    • Monitor bowel functions

Nursing Interventions

Interventions:

  • Routine perineal hygiene
  • Answer call lights quickly and offer the bedpan or urinal to bedridden patients at frequent intervals
  • Rationale:Expected outcomes:

    • These measures can prevent incontinence and decrease the number of incontinent episodes

    • Maintaining adequate fluid intake

    • Experience normal urinary elimination patterns

    • Report relief of bothersome urinary tract symptoms

    • Verbalize knowledge of treatment regime

Body systems to assess

  • Renal
  • Cardiovascular
  • Respiratory
  • Integumentary (skin and temperature)
  • Neurological (altered mental status)

Worst possible complication to anticipate

  • Urosepsis: a systemic infection arising from a urologic source. Prompt diagnosis and effective treatment are critical because it can lead to septic shock

Nursing assessment for identifying complications

  • Physical assessment findings
  • Monitor respiratory status
  • Monitor labs
  • Assess patient for signs of infection and improvement
  • Assess patient for septic shock
  • Vital signs
  • Continuous cardiac monitoring

Nursing interventions if complications develop

  • Obtain cultures from all possible sources, including blood, urine, sputum, oropharynx, and perineal regions, and IV site
  • Begin treatment immediately with antibiotics appropriate for the usual residual flora
  • Monitor vital signs closely

Psychosocial needs of patient and family

  • Determine the functionality of the family and the patient’s and family’s developmental level
  • Discuss treatment plan and any further questions

Evaluation and nursing priorities

Has status improved or not as expected?

  • Thus far, the patient has made some improvements, but not as expected. The patient does not appear to be in acute distress. Upper and lower extremities are mottled in appearance and cool to the touch. Pulses are strong and heart sounds regular and equal with palpation.

Does your nursing priority need to be modified?

  • Yes, monitor for decreased neurological status and respiratory failure.

Nursing priorities and plan of care:

  • Monitor BP, neurological status, and respiratory status.

SBAR Report

Situation:

  • 82-year-old female came to the ED for UTI, showing worsening symptoms of BP 102/50, no urine output in the past 2 hrs, and lactate level 3.2.

Background:

  • Patient had NS IV bolus, and started on Ceftriaxone.

Assessment:

  • Patient is showing decreased neurological status and mottling in upper and lower extremities. Concerned she is becoming septic.

Recommendation:

  • Do you want to do another bolus? Do you wish to draw more cultures? I suggest ICU admission.

Has the status of the patient improved?

  • No, the patient is now exhibiting signs of septic shock with an increase in temperature, RR, and HR as well as a decrease in BP.

Education Priorities and Discharge Planning

  1. Patient must adhere to prescriptions and dietary changes. Exercise is encouraged. Proper fluid intake is needed to maintain kidney function. Schedule follow-up appointments and reinforce the need for regular appointments to monitor health status. Encourage family support and interaction in a healthy lifestyle.
  2. Have the patient repeat back the instructions provided.

Caring and the “Art” of Nursing

  1. The patient may be fearful and nervous about returning home after continuous monitoring in the ICU.
  2. Engage with the patient on a personal level, use active listening, open-ended questions, and offer opportunities for more conversation. Be sympathetic.

Reflection

  1. The scenario reinforced the importance of paying attention to every detail, actively listening to patients, and constantly assessing to keep patients healthy and safe.
  2. Use this experience to improve the level of care provided to future patients, focusing on priority assessment and interventions for disorders.

Sample 2

Sepsis 1. What data from the histories is important and relevant; therefore it has clinical significance to the nurse? Relevant data from present problem Clinical significance  Patient age  Fatigue x3 days  Fever for x24 hrs  Patient reports painful, frequent, burning sensation with urination  Altered Mental Status (confusion)  Weakness  Elderly patients experience confusion more often associated with infections  Pain, urgency and dysuria are common symptoms of UTI  Fever points towards infection Relevant data from social history Clinical significance  Patient is a widow but children help with ADLs.  Lives independently  Lives alone, but can call if help is needed 2. What is the relationship of your patient’s past medical history and current meds? PMH Home meds Pharm class Expected outcome  Diabetes type 2  Hyperlipidemi a  Hypertension  Gout 1. Allopurinol 100mg PO bid 2. ASA 81 mg PO daily 3. Pioglitazone 15 mg PO daily 4. Simvastatin 20mg 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/ anti-gout agents 2. Salicylates 3. Thiazolidinedione/antidiabetic 4. HMG-CoA reductase inhibitor/ lipid lowering agent 5. Beta blocker/ antihypertensive 6. ACE inhibitors/ antihypertensive 7. Loop diuretic 8. Electrolyte replacement 1. Lowers serum uric acid levels 2. Decreases likelihood of platelet aggregation 3. Decreased insulin resistance 4. Lowers total and LDL cholesterol. 5. Decrease BP 6. Decrease BP 7. Diuresis of excess fluid 8. Prevention of potassium depletion, from the Lasix e 3. One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, which disease likely developed FIRST that then initiated a domino effect? a. Hyperlipidemia i. Hypertension ii. Diabetes iii. Gout 1. What VS data are relevant that must be recognized as clinically significant to the nurse? Relevant VS data Clinical significance  Temp: 101.8 F (high)  BP: 102/50 (low)  Orthostatic standing BP 92/42 low with 132 HR  Flank pain  Fever represents sign of infection  Dehydration  Flank pain, chills, and fever indicate an infection involving the upper urinary tract (pyelonephritis) 2. What assessment data are relevant and must be recognized as clinically significant by the nurse? Relevant assessment data Clinical significance  A and O x2  Dizziness when sits up  Dysuria and frequency in urination  Right flank tenderness  Lips dry and oral mucosa tacky dry  Confusion in elderly is a sign of infection and an altered mental state is an atypical symptom of UTI but seen in elderly  Typical symptoms in UTI  Signs of dehydration Radiology Report What diagnostic results are relevant that must be recognized as clinically significant to the nurse? Relevant results Clinical significance No infiltrates or other abnormalities. No change.  Patient is not in respiratory distress. Lab Results CBC Current High/low/WNL? Most recent WBC 13.2 high 8.8 Hgb 14.4 WNL 14.6 Platelets 246 WNL 140 Neutrophil 93 WNL 68 Band form 2 low 1 Relevant Significance Trend  WBC  Hgb  Platelet  Neutrophil  Band form  Indicates infection  Can indicate anemia/bleed  Indicates clotting factor  Low puts pt at risk for infection  May help identify infection  worsening  improvement  worsening  worsening  stable BMP Current High/low/WNL? Most recent Sodium 140 WNL 138 Potassium 3.8 WNL 3.9 Glucose 184 high 128 BUN 35 High 14 Creatinine 1.5 High norm 1.1 Lactate 3.2 High n/a Magnesium 1.9 WNL 1.8 Relevant Significance Trend  Glucose  BUN  Glucose can be elevated for pt’s Diabetes and or stress of being in hospital.  Increased levels seen in dehydration and decreased levels seen in overhydration  Worsening  Worsening UA: Current ABNL/WNL PREVIOUS Color Yellow WNL Yellow Clarity Cloudy ABNL Clear Specific Gravity 1.032 ABNL 1.010 Protein 2+ ABNL 1+ Glucose Neg WNL Neg Ketones Neg WNL Neg Bilirubin Neg WNL Neg Blood Neg WNL Neg Nitrite Pos ABNL Pos LET Pos ABNL Pos MICRO: RBC’s 1 WNL 0 WBC’s >100 ABNL 3 Bacteria LARGE ABNL Few Epithelial Few ABNL Few Relevant Significance Trend  Clarity  Specific Gravity  Protein  Nitrite  LET  WBC’s  Cloudy urine may be caused by the presence of pus, RBCs or bacteria.  The specific gravity of the urine in a dehydrated patient can be expected to be abnormally high  If significant protein is noted at urinalysis, a 24- hour urine specimen should be collected to measure the quantity of protein  Positive Nitrite and LET, both test indicates a urinary tract infection.  Increased WBC’s indicates, bacterial infection in the urinary tract.  Worsening  Worsening  Worsening  Worsening  Worsening  Worsening Lab planning Lab Normal Value Clinical significance Nursing assessments/interventions required Creatinin e Value: 1.5 0.6-1.2 Critical value: 1.5  illustrates the filtration capacity of the glomerulus  combined with BUN it illustrates kidney function  Educate patient to reduce protein intake.  Increase Fluid Intake.  Improve Urinary Tract Health.  Reduce Blood Pressure. Lab Normal Value Clinical significance Nursing assessments/interventions required Lactate Value: 3.2 0.5 – 1.6  Ordered when signs of sepsis, shock, MI, severe  Early recognition is key Critical Value: 3.2 CHF, kidney failure, or uncontrolled diabetes is present  a greater increase in lactate means a greater severity of the condition  When associated with lack of oxygen, an increase in lactate can indicate that organs are not functioning properly  May indicate metabolic acidosis  Administer bicarb if r/t metabolic acidosis  Monitor pt if also taking metformin for diabetes, especially in the case of poor kidney function  Correct dehydration (if applicable) 1. What is the primary problem that your patient is most likely presenting with?  Urinary tract infection 2. What is the underlying cause/pathophysiology of this problem?  Bacterial contamination of the sterile urine usually occurs by retrograde movement of gram-negative bacilli into the urethra and bladder and then to the ureter and kidney. The infection causes an inflammatory response causing edema in the bladder wall which brings on symptoms of bladder fullness with decreased volumes of urine and producing the urgency and frequency of urination associated with UTI. Medical management Care provider orders Rationales Expected outcome  Establish peripheral IV  NS 1000 mL bolus  Acetaminophen 650 mg  Ceftriaxone 1g IVPB… after blood and urine cultures obtained  Morphine 2 mg IVP q2 hrs PRN-pain  IV access for fluids and antibiotics  Fluids for rehydration  Tylenol for temperature and pain.  Antibiotic for UTI  Pain reliever  Better fluid balance and rehydration.  Pain and fever reduced  Treat infection Priority setting: which order do you implement first and why? Care provider orders Order of priority Rationale  Establish peripheral IV  NS 1000 mL bolus  Acetaminophen 650 mg  Ceftriaxone 1g IVPB… after blood and urine cultures obtained  Morphine 2 mg IVP q2 hrs PRN-pain 1. IV access 2. Blood and Urine cultures 3. NS bolus 4. IVPB Ceftriaxone 5. Acetaminophen 6. Morphine (if patient requests)  IV access fastest way to rehydrate patient and give medications.  Obtain cultures (blood while getting IV access) Needs to be obtained before initiating antibiotic.  NS bolus for hydration and decreased BP.  Antibiotic started  Acetaminophen to decrease temperature.  Morphine PRN Medication dosage calculation Medication/ dose Mechanism of action Volume/time frame to safely administer Nursing assessment/consideration Ceftriaxone 1g IVPB  Bind to the bacterial cell wall membrane, causing cell death. 50 ml Hourly rate IVPB:  Obtain history of any reactions to penicillins or cephalosporins.  Observe for signs of anaphylaxis.  Monitor bowel functions. Nursing Interventions: Rationale Expected outcome  Routine perineal hygiene.  Answer call lights quickly and offer the bedpan or urinal to bedridden patients at frequent intervals.  Fluids IV and encourage PO.  These measures can prevent incontinence and decrease the number of incontinent episodes.  Maintaining adequate fluid intake.  Experience normal urinary elimination patterns  Report relief of bothersome urinary tract symptoms  Verbalize knowledge of treatment regime What body systems will you most thoroughly assess based on the primary/priority concern?  Renal  Cardiovascular  Respiratory  Integumentary (skin and temperature)  Neurological (altered mental status) What is the worst possible complication to anticipate?  Urosepsis is a systemic infection arising from a urologic source. Its prompt diagnosis and effective treatment are critical because it can lead to septic shock What nursing assessment will you need to initiate to identify this complication if developed?  Physical assessment findings  Monitor respiratory status  Monitor labs  Assess pt for signs of infection and improvement  Assess pt for septic shock  Vital signs  Continuous cardiac monitoring What nursing interventions will you initiate if this complication develops?  The causative organisms of sepsis are usually gram-negative bacteria, so when sepsis is suspected, immediately obtain cultures from all possible sources, including blood, urine, sputum, oropharynx and perineal regions, and IV site. Treatment immediately begins with antibiotics appropriate for the usual residual flora. When the culture and sensitivity results come back, the antibiotic in use may be continued or changed based on the results. The patient’s condition is considered critical, monitor vital signs closely. What psychosocial needs will this pt and/or family likely have that will need to be addressed and how can the nurse address these needs?  The nurse must determine the functionality of the family and the patient’s and family’s developmental level.  Discuss treatment plan and any further questions. PART IV Relevant VS Clinical Significance  Increased T (101.8)  Increased respiratory rate  Increased T and RR indicates infection. Monitor for acidosis and respiratory  Increased BP from 98/50 to 102/50 failure. Relevant Assessment Data Clinical Significance  Resp – lungs clear upon assessment  GU – 200 mL of cloudy urine indicates dehydration and possible infection  Alert and orientated x2  Mottling in upper and lower extremities  Encourage fluids and maintain IV fluids.  Clinical signs of septic shock include alteration in neurologic status; decreased urine output 1. Has status improved or not as expected?  Thus far, the pt has made some improvements, but not as expected. Pt does not appear to be in acute distress. UE and LE mottled in appearance and cool to the touch. Pulses are strong and heart sounds regular and equal with palpation. 2. Does your nursing priority need to be modified in any way after this evaluation?  Yes, monitor for decreased neurological status and respiratory failure. 3. Based on your current evaluation, what are your nursing priorities and plan of care?  Monitor BP, neurological status, and respiratory status. S – 82 yr old female came in to the ED for UTI, and is showing worsening symptoms of BP 102/50, no urine output in the past 2 hrs, and lactate level 3.2. B – Patient had NS IV bolus, and started on Ceftriaxone. A – Patient is showing decreased neurological status and mottling in upper and lower extremities. I am concern she is becoming septic. R – Do you want to do another bolus? Do you wish to draw more cultures? I suggest she be an ICU admission. 4. Has the status of the pt improved at this point and what data supports this?  No, the patient is now exhibiting signs of septic shock with an increase in temperature, RR, and HR as well as a decrease in BP. S – I’m giving report on Jean Kelly an 82 yr female admitted for UTI and possible sepsis. B – Patient has history of HTN, hyperlipidemia, DM, and gout. She came in to the ED today after feeling weak for last 3 days and a fever the last 24 hrs. She reported painful, burning and frequency of urination. A – Patient was started on Ceftriaxone and received 2 1000ml 0.9% NS boluses. Inserted Foley catheter, with 200ml of cloudy urine collected. Patient’s neuro status has decreased to A and O x2. Extremities are mottled and cool to touch. Patient had a critical lactate level of 3.2 and elevated creatinine and BUN. UA showed increased WBC’s. Last set of VS HR 92 BP 114/64 R 20 T 100.6 O2 sat 98% on RA R – Transfer to ICU, monitor urine output and signs of Sepsis. Education Priorities and Discharge Planning 1. Patient must adhere to prescriptions and dietary changes. Exercise is encouraged. Along with diet, proper intake of fluid is needed to maintain kidney function. A follow up appointment should be scheduled and reinforce the need for regular appointments to monitor health status. Encourage family support and interaction in healthy lifestyle. 2. Have the patient repeat back to me the instructions I have taught her. Caring and the “Art” of Nursing 1. The patient may be very fearful and nervous about returning home after continuous monitoring in the ICU. 2. It is important that the patient know how involved you (as her nurse) are in her care. Relate to her on a personal level, engage in active listening, use open-ended questions, and offer her the opportunity to engage in more conversation. Be sympathetic. Reflection 1. This scenario reinforced the fact that we must pay attention to every detail. We need to be actively listening to our patients and constantly assessing in an effort to keep our patients healthy and safe. 2. I can use this in the future to improve the level of care that I give to my patients. This scenario involved the complication of a disorder and why we need to know our priority assessment and interventions for disorders.