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Urinary Tract Infection Case Study (45 min)

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Mrs. Phillips is an 84 year old female who arrived to the Emergency Department from a nursing home, where caregivers report she has altered mental status, confusion, and weakness that they just noticed this morning. The nurse inserts 2 large bore PIV’s and draws blood for a chemistry and complete blood count, as ordered by the Provider, who is concerned she may be having a stroke.

Critical Thinking Check
Bloom's Taxonomy: Application

What initial nursing assessments should be performed??

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic testing do you anticipate for Mrs. Phillips?

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Mrs. Phillips’s vitals are as follows:

HR 122 RR 24

BP 92/58 SpO2 92%

Temp 103.6°F

Her NIHSS score is 2, CT scan is negative for an intracranial bleed, and the neurologist believes she is NOT having a stroke.  The nurse is called into the room by the caregivers as the patient has wet herself. The nurse notes a foul, sour odor to the urine. Mrs. Phillips’ blood pressure is now 88/52. The nurse notifies the Provider.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What orders do you anticipate from the provider?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What may be going on with Mrs. Phillips physiologically?

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The provider places orders for the following:

Keep SpO2 > 92%

Blood Cultures x 2

Urinalysis

Urine Culture

500 mL NS IV bolus STAT

100 mL/hr NS IV continuous infusion

Vancomycin 1,000 mg IV x 1 dose NOW.

 

Critical Thinking Check
Bloom's Taxonomy: Analysis

Which order should be implemented first? Why?

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The nurse obtains 2 sets of blood cultures and the UAP obtains a sterile urine sample via I&O cath. The UAP reports cloudy, foul-smelling urine.  The nurse initiates the IV fluid bolus and requests the Vancomycin from the Pharmacy. Mrs. Phillips’ caregiver asks why she is so confused?

 

Critical Thinking Check
Bloom's Taxonomy: Analysis

Why is Mrs. Phillips presenting with Altered Mental Status?

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After 3 days of treatment with IV antibiotics, Mrs. Phillips is awake and oriented x 2-3 (she has dementia at baseline and occasionally thinks it’s 1946). She is calm, conversing with staff, and able to ambulate the halls. She will be discharged home with PO antibiotics tomorrow.

Critical Thinking Check
Bloom's Taxonomy: Application

What discharge teaching should be provided to Mrs. Phillips and to the caregivers at Mrs. Phillips’ nursing home?

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