Urinal Tract Infection Patient: Client Composite

Introduction: History of Presenting Illness

Mrs. X is an 88-year-old female patient who was brought to the emergency department of the hospital on the 8th of February, 2016, with a few days’ histories of generalized weakness, suprapubic pain, and urinary frequency. She also complained of worsening of her chronic leg edema. She denied any chest pain or shortness of breath. She did not have any fever or flank pain. The patient lived alone in her trailer and was supported by her daughters. She had a DNR (do not resuscitate order) as per the patient’s wish, which her family was aware of and agreed with the arrangement.

Past Medical History

Mrs. X had a previous history of hypertension, dementia, osteoarthritis, and coronary artery disease. On the 19th of February, the patient was diagnosed with a new C. difficile infection, which was accompanied by abdominal discomfort. Therefore, she was started on oral Flagyl 500mg TID. A day afterward (20/2/2016), the patient’s condition had improved. However, she still complained of abdominal pain and ongoing diarrhea. Her vital signs were stable.

Surgical History

Mrs. X had left arm amputation secondary to wound injury at the age of 17.

Primary Diagnoses

The patient’s primary diagnoses included urinal tract infection (UTI), rhabdomyolysis, and peripheral edema.

Urinal tract infection is a condition where infecting microorganisms gain entry into the urinal tract. The type of infection depends on the section of the urinary tract that is affected. Acute pyelonephritis occurs when the kidneys are affected and are characterized by flank pain, fever, chills, and vomiting (Rane & Dasgupta, 2013). Cystitis occurs when the bladder is affected, leading to lower abdominal discomfort, blood-stained urine, regular painful urination, and pelvic pressure. Urethritis, conversely, occurs when the urethra is affected, leading to the production of urethral discharge and a burning sensation when passing urine. Sexually active women were more likely to have the infection though it could occur in the elderly who were not sexually active as well as children. Mrs. X had lower abdominal discomfort and urinal frequency, which indicated that she had cystitis (Catto, 2012).

Rhabdomyolysis is the disintegration of muscle tissues, often leading to the release of constituents of the muscle fiber into the blood. Muscle damage leads to the liberation of myoglobin into the bloodstream hence necessitating filtration of the blood through the kidneys. The myoglobin produced is deleterious to the kidney cells. Therefore, rhabdomyolysis leads to kidney damage. The causes of this condition include inherent muscle disorders, trauma or accidents, muscle ischemia, severe exertion, expensive muscular exertion, hypophosphatemia, protracted surgeries, extreme dehydration, and using certain drugs, for example, amphetamines, cocaine, and statins. Severe dehydration and extreme body temperatures have also been reported to cause rhabdomyolysis. The main indicators of this disorder include the production of dark-colored urine, muscle tenderness, stiffness of joints, general body weakness as well as the weakness of the affected muscles. Joint pain and fatigue are also common. Mrs. X presented with suprapubic pain as well as muscular and joint aches, which point towards rhabdomyolysis.

The swelling of feet, legs, and ankles, which is referred to as peripheral edema, is the accumulation of fluid in these parts of the body. The condition is not usually painful unless it is caused by an injury. Swelling is usually more evident in the lower sections of the body due to the influence of gravity. Some of the leading causes of peripheral edema include being overweight, standing for long periods, using certain hypertensive medications, steroids, estrogen, non-steroidal anti-inflammatory drugs, and antidepressants, including tricyclics. Staying in a restricted position, such as during car rides or flights, may also lead to peripheral edema. Inadequate pumping of blood by the veins, liver cirrhosis, malfunction of the heart, liver, or kidney, inflammation of the membrane surrounding the heart, and blockage of the lymph duct may also bring about peripheral edema. Mrs. X had a medical history of elevated blood pressure and was on hypertensive medication, which was a likely cause of her peripheral edema. Additionally, she had coronary artery disease, which could have affected blood flow to the limbs. Some of the danger signs in peripheral edema include dizziness, faintness, shortness of breath, confusion, and chest pain. Mrs. X had two of these symptoms (dizziness and faintness), which warranted her hospital admission.

Secondary Diagnoses

The patient’s secondary diagnoses included Clostridium difficile, dementia, hypertension, osteoarthritis, coronary artery disease, and left arm amputation secondary to a wound injury at the age of 17.

Clostridium difficile, which is often abbreviated as C. difficile or C. diff, is a bacterial infection characterized by symptoms such as diarrhea and irritation of the colon (Eckert et al., 2015). The elderly receiving hospital care or in other long-term care facilities are mostly susceptible to C. diff infections (Chakra, Pepin, Sirard, & Valiquette, 2014). More often, the infection occurs as a result of prolonged usage of antibiotics. Nevertheless, the infection can also be present in people belonging to other age groups who have no history of antibiotic use or staying in healthcare facilities. C. difficile is normally found in the large intestines of normal people without causing disease because other gastrointestinal bacteria keep it in check. However, the usage of broad-spectrum antibiotics often reduces the populations of other bacteria, thus providing C. difficile an opportunity to thrive and cause infections. The symptoms of mild C. diff infection include passing watery stool about three to four times a day for two to three days, as well as mild stomach cramping and tenderness. On the other hand, severe C. diff infections are characterized by passing watery stool up to 15 times a day, fever, blood-stained or puss-tinged stool, dehydration, loss of appetite, queasiness, severe abdominal cramping, bloated abdomen, kidney malfunction, and elevated white blood cell count (Chakra et al., 2015). Mrs. X had an increased white blood cell count, which was an indication of severe infection that necessitated extended hospital admission. She also acquired the infection as a consequence of antibiotics used to treat her UTI as well as hospital care during the period of admission.

Dementia is a term that denotes a wide range of symptoms that correlate with the reduction in memory and the ability to think properly and carry out normal day-to-day activities. Alzheimer’s disease is the most common form of dementia. Dementia hampers features such as memory, communication, concentration, visual discernment, and reasoning capacity (Swinton, 2012). For a diagnosis of dementia to be made, at least two of the above-mentioned features must be affected (Shea, 2012). The main cause of dementia is irreversible damage to brain cells. Mrs. X has a history of dementia and cannot remember some of the things that happened to her, such as recent falls, which is a likely cause for rhabdomyolysis, which is one of her primary diagnoses.

Hypertension is a medical condition that is marked by elevated blood pressure. In this condition, the long-term pressure of the blood against the arterial walls is higher than normal, thereby increasing the chances of developing heart complications. Mrs. X has a history of hypertension. However, the condition is under control and is not a direct cause for admission because her current blood pressure is within the normal range.

Coronary artery disease is a heart disease that occurs when the arteries that convey blood to the heart harden and become narrow due to the accumulation of cholesterol and other substances (Barsness & Holmes, 2012). As the condition worsens, less blood reaches the heart muscles, thereby diminishing the amount of oxygen. Such a state may lead to chest discomfort or heart attack.

Osteoarthritis is a longstanding degenerative joint disease that leads to the disintegration of the cartilage that cushions joints. Consequently, there is stiffness of joints and inflammation accompanied by pain (Acton, 2013). The common signs include stiffness of joints, particularly after waking up or resting. It then becomes difficult to perform certain activities that require physical exertion. The main causes of osteoarthritis include genetics, extreme weight gain, and injury. Advancing in age also increases an individual’s chances of developing osteoarthritis. This disorder has no cure. However, certain medications can prevent it from getting worse. Physical exercise and joint replacement surgery are also useful in managing the condition.

Medical Treatments

All medical treatments provided to the patient, laboratory tests, and medical procedures are summarized in the appendix.

Head to Toe Systematic Assessment

Subjective Data

  • General: Mrs. X was generally frail due to her multiple comorbidities. She felt lethargic due to her illness. She was unable to move due to the aches in her joints.
  • HEENT: No headache reported, no blurred or double vision.
  • Neck: Absence of stiffness, pain, no soreness.
  • Respiratory: The patient did not complain of shortness of breath.
  • Cardiovascular: No chest pains, no palpitations, no syncope or orthopnea.
  • Gastrointestinal: There was a slight decline in appetite, abdominal discomfort, and tenderness, queasiness. Additionally, there was mild diarrhea.
  • Peripheral vascular: None reported
  • Urinary: Frequency of urination accompanied by pain due to a UTI. The patient noticed that her urine was darker than usual.
  • Musculoskeletal: Fatigue and mild muscular and joint aches.
  • Psychiatric: No signs of depression. The patient was oriented to time, people and place.
  • Neurological: The patient reported no sensitivity to cold. Additionally, she denied stroke, seizures, or numbness.
  • Skin: No swellings, bruises, or rashes.
  • Hematologic: Not anemic. The patient did not bleed easily.
  • Endocrine: No excessive thirst, heat, or cold
  • Allergic/Immunologic: No known food or drug allergy.
  • General: An 88-year-old female, normotensive, was lying on a stretcher and was in no apparent distress. The patient was alert and oriented to person, place, and time. The patient is also good-natured and well-groomed.
  • Vital signs: Weight: 135 lbs, Height: 5 feet 5 inches, BMI: 22.46, BP: 126/60, pulse 84, RR: 16, T: 36.2oC, O2 saturation: 95% on room air.
  • HEENT: Normocephallic, no lesions, PERRL/EOM intact, no cerumen obstruction. Conjunctiva and sclera clear.
  • Chest/Lungs: There was some decreased air entry with crackles bilaterally, but no wheeze.
  • Heart/Peripheral Vascular: S1 and S2 were noted. No murmur, rub or gallop. Peripheral pulses could be felt in all limbs, edema was observed in her left foot.
  • Skin: Supple, no rashes present.
  • Abdomen: Her abdomen was soft, although she was a bit tender in the suprapubic area, but with no guarding and normal bowel sounds.
  • Urinary: Absence of burning sensation during urination. No urethral discharge.

Nursing Problem of High Priority

While caring for Mrs. X, the main nursing problem of high priority that I identified was the possibility of renal failure resulting in fluctuations between fluid volume excess, dehydration, and electrolyte imbalance. The patient suffered from rhabdomyolysis, which has been shown to lead to renal damage due to the secretion of myoglobin into the blood (Giuliani et al., 2013). Electrolyte irregularities are commonplace in patients with rhabdomyolysis, including elevated serum potassium and phosphate levels, low calcium, and albumin levels (Zimmerman & Shen, 2013). Elevated calcium arises from muscle damage and renal inadequacy, which may lead to life-threatening arrhythmias if not handled promptly. Acute kidney failure has also been reported in approximately 35% of grownup patients with rhabdomyolysis (Giuliani et al., 2013). In addition, there was a possibility that her leg edema, which did not have a clear cause, could have been caused by organ damage (liver, kidney, or heart). One of the major complications of C. diff infections is kidney failure and dehydration (Thongprayoon et al., 2015). While caring for the patient, I observed that she showed signs of dehydration due to the frequent passing of watery stool. The patient also reported increased urination frequency due to her urinary tract infection. The patient’s decreased mobility also put her at risk of other disorders. Therefore, precautions were taken to ensure that the patient’s renal function was maintained.

Two Nursing Interventions

The first nursing intervention was monitoring the patient’s renal function by testing for crucial enzymes such as creatinine kinase with morning blood work. At first, her creatinine levels were within the normal limit. However, at some point, the creatinine levels rose, thereby making it necessary to withhold the statins and provide intravenous fluids. The patient received intravenous Lasix followed by oral Lasix, which is a mild diuretic to avoid fluid overload. However, she soon developed dehydration again, necessitating the withdrawal of Lasix.

Apart from medication, the patient’s fluid and electrolyte balance was also maintained through a proper diet during her hospital stay. She was provided with plenty of fluids containing water, salt, and sugar, for instance, fruit juices, soups, and soft drinks. She was also provided with plenty of fruits and vegetables. Her diet comprised starchy foodstuffs such as noodles, rice, oatmeal, and potatoes. During her recovery, the patient received advice regarding hygienic practices to prevent the reinfection with C. difficile. For example, she was reminded to wash her hands thoroughly using soap and warm water. Mrs. X’s daughters were also asked to ensure adequate hand hygiene whenever they touched their ailing mother. Mrs. X was also cautioned against the unnecessary usage of antibiotics for mild viral illnesses such as the flu. She was asked to develop a wait-and-see approach as these illnesses often resolved on their own.

The second nursing intervention was providing physiotherapy and occupational therapy to help the patient regain mobility. Mrs. X usually ambulated with the help of a walker and would go to the bathroom with minimal assistance prior to the hospital admission. Physiotherapy also served as a form of exercise for the patient to improve her secondary diagnoses such as hypertension and coronary artery disease that required exercise. Rhabdomyolysis among the elderly was often caused by trauma from falls. However, the patient denied having a recent fall, probably because she could not remember due to her dementia. I educated the patient on ways of preventing rhabdomyolysis, such as learning to recognize symptoms of dehydration and injuries related to heat.

Another vital part of the care provided to the patient was advice regarding the prevention of urinal tract infections. I advised Mrs. X to empty her bladder frequently as soon as she felt the need to pass urine (Catto, 2012). The most effective way of emptying the bladder was to take her time to ensure that the bladder was empty. She was also advised to wipe from front to back and take plenty of water. She was advised to use a shower as opposed to the bathtub and keep off feminine hygiene products and infused baths.

Conclusion

Overall, my care for Mrs. X was effective, as was witnessed by her improving physical condition under my care. This opportunity has provided me with valuable experience in nursing care. I have gained immense knowledge and experience handling elderly patients with multiple comorbidities. I have learned that in patients with multiple disorders, one condition may cause or influence the manifestation of another disease. For example, diseases requiring antibiotic usage and hospital stays often lead to the production of other disorders, as was the case in Mrs. X when treating her UTI with antibiotics and keeping her in the hospital to manage her condition led to the development of C. diff infection.

Therefore, I learned that as a nurse, I need to take precautions to boost the patient’s immune system to prevent the development of such opportunistic infections. I also noted that it is crucial to monitor the effect of a drug on a patient’s recovery progress and change to a stronger drug if the patient’s condition did not improve. For example, Mrs. X’s C. diff infection did not show improvement as fast as was anticipated because the frequency of diarrhea reduced, but the Bristol remained at 6, which made it necessary to change her antibiotic from Flagyl to vancomycin. Monitoring the effect of drugs was also necessary for the maintenance of the patient’s fluid and electrolyte levels through the administration of Lasix. Lasix, a mild diuretic, was useful in preventing fluid overload. However, in excessive quantities, Lasix could also lead to dehydration and loss of electrolytes. Therefore, it was necessary to monitor the drug’s effect on the patient.

I also learned that it is useful to inform the patient’s family about the kind of treatment that their loved ones received to alleviate their worries. Mrs. X’s daughter kept inquiring about her mother’s condition and when she would be discharged from the hospital. I took it upon myself to inform her about the patient’s health status and the need to keep an eye on the patient until she was well enough. I also informed her that C. diff, which her mother developed while in the hospital, could lead to adverse consequences such as toxic megacolon, bowel perforation, renal failure, and death if the patient’s condition was not monitored.

Appendices

Medical Treatments

In the event the client’s actual results are not available, state the expected findings that are commonly noted in the research regarding the client’s diagnoses

Medications
Dose, Route, Times
Classification & Action Interpretation
(Why is the client on this medication? Explain how this medication links to the diagnosis / condition)
Amlodipine (Norvasc)
10 mg, po, 0900
Antihypertensive – it produces a relaxation of coronary vascular smooth muscle and coronary vasodilation; directly acts on vascular smooth muscle to produce peripheral arterial vasodilation reducing blood pressure (Skidmore-Roth, 2015, p. 61) Patient has secondary diagnosis of hypertension and coronary heart disease. This
Clopidogrel (Plavix)
75 mg, po, 0900
Platelet aggregation inhibitor – it inhibits platelet aggregation by blocking the binding of ADP to its platelet P2Y12receptor (Skidmore-Roth, 2015, p. 281)
Dalteparin (Fragmin)
5000 units, subcut, 1700
Anticoagulant – it inhibits factor Xa/IIa (thrombin), resulting in anticoagulation (Skidmore-Roth, 2015, p. 318)
Metronidazole (Flagyl)
500 mg, po, 0900 & 1400 & 2100
Antiinfective –it inhibits bacterial nucleic acid synthesis by disrupting DNA structure (Skidmore-Roth, 2015, p. 788) Treatment of C. diff
Pantoprazole (Pantoloc)
40 mg, po, 0900 & 2100
Proton pump inhibitor – it suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump (Skidmore-Roth, 2015, p. 916)
Quetiapine (Seroquel)
12.5 mg, po, 2100
Antipsychotic – it is an antagonist at multiple neurotransmitter receptors in the brain (Skidmore-Roth, 2015, p. 1007)
Saccharomyces (Florastor)
500 mg, po, 0900 & 2100
Dietary supplement- it is a nonpathogenic live yeast probiotic, acting as temporary flora to help re-establish the normal gastrointestinal microflora. It also suppresses pathogenic bacteria growth. (Skidmore-Roth, 2015, p. 597)
Vancomycin
125 mg, po, start 25/02/16, stop 2 weeks later
Antiinfective – it inhibits bacterial cell wall synthesis and blocks glycopeptides (Skidmore-Roth, 2015, p. 1216)
Acetaminophen (Tylenol)
650 mg, po, every 4 hours
Nonopioid analgesic, antipyretic – it inhibits the synthesis of prostaglandins in the central nervous system and work peripherally to block pain impulse generation; antipyretic action results from inhibition of hypothalamic heat-regulating center (Skidmore-Roth, 2015, p. 8)
Clonazepam (Klonopin)
0.5 mg, po, BID
Anticonvulsant – it enhances the activity of GABA and depresses nerve transmission in the motor cortex to suppresses the spike-and-wave discharge in absence seizures (Skidmore-Roth, 2015, p. 277)
Dimenhydrinate (Gravol)
25-50 mg, IV, every 4-6 hours
Antiemetic – it competes with histamine for H1-receptor sites in the gastrointestinal tract, blood vessels, and respiratory tract; it also blocks chemoreceptor trigger zone and decrease vestibular stimulation (Skidmore-Roth, 2015, p. 373)
Dimenhydrinate (Gravol)
25-50 mg, po, every 4-6 hours
Antiemetic – it competes with histamine for H1-receptor sites in the gastrointestinal tract, blood vessels, and respiratory tract; it also blocks chemoreceptor trigger zone and decrease vestibular stimulation (Skidmore-Roth, 2015, p. 373)
Lorazepam (Ativan)
1 mg, po, at bedtime
Sedative, antianxiety – it potentiates the actions of GABA at several sites within the central nervous system, which results in hyperpolarization and stabilization (Skidmore-Roth, 2015, p. 725)
Nitroglycerin (Nitrolingual)
0.4 mg (1 spray), sublingual as directed
Coronary vasodilator – it reduces preload and afterload; dilates coronary arteries, arterial and venous beds systemically; improves blood flow through coronary vasculature (Skidmore-Roth, 2015, p. 860)
Ondansetron (Zofran)
4-8 mg, IV, every 8 hours
Antiemetic – it works by blocking the action of serotonin both peripherally and centrally, which may cause nausea and vomiting (Skidmore-Roth, 2015, p. 886)
Ondansetron (Zofran)
4-8 mg, po, every 8 hours
Antiemetic – it works by blocking the action of serotonin both peripherally and centrally, which may cause nausea and vomiting (Skidmore-Roth, 2015, p. 886)
Laboratory tests
Blood work
(include client lab value)

Urinalysis
(include client lab value)

Normal finding
(What are the normal parameters or values for each lab test?)
Interpretation
(Describe the lab test. Why does the client have these results? Even if the client’s lab results are normal, explain why this lab test is normally done. Provide examples of conditions that could cause high or low values.)
Hematology
White Blood Cell (WBC)
7.23 x 109/L – Normal
5-10 x 109/L
Red Blood Cell (RBC)
3.99 x 1012/L – Low
Adult female:
4.2-5.4 x 1012/L
Hemoglobin (Hb)
126 mmol/L – Normal
Adult female:
120-160 mmol/L
Hematocrit (Hct)
39% – Normal
Adult female:
37%-47%
Mean Corpuscular Volume (MCV)
97.8 fL – High
80-95 fL (80-95 mm3)
Mean Corpuscular Hemoglobin (MCH)
31 pg – Normal
27-31 pg
Mean Corpuscular Hemoglobin Concentration (MCHC)
32.2 g/dL – Normal
32-36 g/dL
Red Blood Cell Distribution Width (RDW)
14.3% – Normal
11%-14.5%
Platelet Count
397 x 109/L – Normal
150-400 x 109/L
Neutrophils
3.44 x 109/L – Normal
2.5-8.0 x 109/L
Lymphocytes
3.11 x 109/L – Normal
1.0-4.0 x 109/L
Monocytes
0.41 x 109/L – Normal
0.1-0.7 x 109/L
Eosinophils
0.23 x 109/L – Normal
0.0-0.5 x 109/L
Basophils
0.05 x 109/L – Normal
0.02-0.05 x 109/L
Chemistry
Sodium (Na)
138 mmol/L – Normal
136-145 mmol/L
Potassium (K)
4.3 mmol/L – Normal
3.5-5.0 mmol/L
Chloride (Cl)
102 mmol/L – Normal
98-106 mmol/L
Carbon Dioxide (CO2)
26 mmol/L – Normal
21-28 mmol/L
Anion Gap (AG)
10 mmol/L – Normal
12+4 mmol/L
Blood Urea Nitrogen (BUN)
11 mmol/L – High
3.6-7.1 mmol/L
Creatinine
103 umol/L – Normal
53-106 umol/L
Coagulation
International Normalized Ratio (INR)
1.1
0.8-1.2
Activated partial thromboplastin time (aPTT)
40 seconds – Normal
30-40 seconds
Urinalysis
pH
6.5 – Normal
4.6-8.0
Specific Gravity
1.010
1.005-1.030
Protein
Negative – Normal
< 150 mg/day
Glucose
Negative – Normal
Negative
Ketones
Negative – Normal
Negative
Blood
Negative – Normal
Negative
Nitrates
Negative – Normal
Negative
Bilirubin
Negative – Normal
Negative
Uroblinogen
3.2 mg/24 hr
0.5-4.0 mg/24 hr
Leuokocyte Estearase
1+ – High
Negative
Red Blood Cell
10-14/high-power field – High
0-4/high-power field
White Blood Cell
5-9/low-power field – High
0-5/low-power field
Bacteria
1+/high-power field – High
Negative
Urine Studies
Urine Culture and Sensitivity (Urine C&S)
< 10,000 CFU/mL – no significant growth
Negative: < 10,000 colony-forming units (CFU)/mL
Stool Studies
Stool for Culture and Sensitivity (C&S)
Positive for toxin B gene – C. difficle positive
Normal intestinal flora

Medical Treatments

In the event the client’s actual results are not available, state the expected findings that are commonly noted in the research regarding the client’s diagnoses

Procedures
  • Scopes
  • Surgical
Explanation
(Describe the scope or surgery using literature)
Interpretation
(Why did your client have this procedure done? What were the client findings of this procedure?)
This section of the paper should include all surgeries past and present and any scopes that the client has had related to their diagnosis (IE client’s with GERD may have had an endoscopy)
None
Diagnostic tests
  • Xrays
  • Scans
Explanation
(Describe the test using literature)
Interpretation
(Why did the client have this test done? What were the client’s findings of this test?)
Chest X-Ray Examples of diagnostic tests include: Chest xray, ultrasound, CT & MRI scans, ECG, EEG
Abdomen X-Ray
Abdomen CAT Scan
Abdomen Ultrasound
Electrocardiography (ECG)