Urosepsis-Case Study- Keith RN PDF

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Urosepsis-Case Study- Keith RN...

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Urinary Tract Infection/Urosepsis

Jean Kelly, 82 years old Primary Concept Infection Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Fluid and Electrolyte Balance 3. Thermoregulation 4. Clinical Judgment 5. Patient Education

© 2016 Keith Rischer/www.KeithRN.com

FUNDAMENTAL Reasoning: 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. 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: Pt is an 82-year-old woman who has Signs and symptoms suggest the presence of a UTI. Studies have been feeling more fatigued. Has shown that confusion in an elderly pt is a common sign and symptom of an infection in the urinary tract. experienced fever within the last 24hrs. Reports painful, burning, and frequent urination for the last week. Reports being weak and unable to get out of bathtub. Daughter concerned about pt’s confusion. Pt has no history of confusion.

RELEVANT Data from Social History: Pt lives independently in a senior apartment retirement community due to being widowed. Pt has two daughters who are involved in her life. Pt wears life alert button in case of emergencies.

© 2016 Keith Rischer/www.KeithRN.com

Clinical Significance: She is capable of caring for herself and has a strong support system in place in the event that she cannot care of herself. The life alert button offers safety, security, and assistance in the event she would have an emergency at home while alone. This provides a safe environment that she can return to upon discharge.

Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins: 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 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: Supine Standing

HR: BP: 110 102/50 132 92/42

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Temp: 101.8F Temp is an indicator of infection based on the fact that it’s caused a P: 110 fever. RR: 24 Pulse is elevated and an indicator that the heart is trying to BP: 102/50 compensate. The heart beats faster to control pressure with the Pain: 5/10, Ache, Right Flank, decreased blood volume with the increased pulse. This could very Continuous well be an indicator for fluid volume deficit. Respiratory rate is elevated and an indicator that the lungs are trying Orthostatic Hypotension to compensate. Blood pressure is low and decreased +/- 20 with change of position which indicates orthostatic hypotension.

© 2016 Keith Rischer/www.KeithRN.com

Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes/Lab/diagnostic Results: Complete Blood Count (CBC): WBC (4.5-11.0 mm 3) Hgb (12-16 g/dL) Platelets (150-450x 103/µl) Neutrophil % (42-72) Band forms (3-5%)

Current: 13.2 14.4 246 93 2

High/Low/WNL? HIGH WNL WNL HIGH LOW

Previous: 8.8 14.6 140 68 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 is elevated and indicates presence of The trend shows that the patient is WBC worsening. infection. Hgb WBC, Platelets, Neutro%, and Band forms Hgb decreased and will need to be Platelets have all increased. While Hgb decreased. assessed if this is due to traumatic blood Neutro% loss or due to fluid volume deficit. Band Forms Platelets are elevated and indicate the body is trying to fight off an existing infection. Neutro% and Bands being present and elevated is a concern as it is an indicator for infection.

Basic Metabolic Panel (BMP): Sodium (135-145 mEq/L) Potassium (3.5-5.0 mEq/L) Glucose (70-110 mg/dL) BUN (7 - 25 mg/dl) Creatinine (0.6-1.2 mg/dL) RELEVANT Lab(s): Glucose BUN Creatinine

Current: 140 3.8 184 35 1.5

High/Low/WNL? WNL WNL HIGH HIGH HIGH

Previous: 138 3.9 128 14 1.1

Clinical Significance: TREND: Improve/Worsening/Stable: The trend shows that the patient is Glucose being elevated may be an indicator of diabetes mellitus type II. This worsening. also could be elevated in response to the infection and the stress it’s putting on the body. BUN and creatinine are elevated which indicates kidney function impairment.

© 2016 Keith Rischer/www.KeithRN.com

Misc. Labs: Magnesium (1.6-2.0 mEq/L) Lactate (0.5-2.2 mmol/L) RELEVANT Lab(s): Lactate

High/Low/WNL? WNL HIGH

Clinical Significance: Lactate being elevated is an indicator of sepsis possibly due to kidneys not being able to perfuse correctly. Should be considered a critical value if value is greater than 2.

Urine Analysis (UA): Color (yellow) Clarity (clear) Specific Gravity (1.015-1.030) Protein (neg) Glucose (neg) Ketones (neg) Bilirubin (neg) Blood (neg) Nitrite (neg) LET (Leukocyte Esterase) (neg) MICRO: RBC’s (...