Chat with us, powered by LiveChat URINARY TRACT INFECTION VIRTUAL SIMULATION ? Scenario # 1 You are working in an extended care facility when M.Z.’s daughter brings her mother in for a week’s stay while she goes on a planned vacation… | paledu.org
  
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URINARY TRACT INFECTION VIRTUAL SIMULATION Scenario # 1 You are…

URINARY TRACT INFECTION VIRTUAL SIMULATION

 

Scenario # 1

You are working in an extended care facility when M.Z.’s daughter brings her mother in for a week’s stay while she goes on a planned vacation. M.Z. is an 89-year-old widow with a 4-day history of nonlocalized abdominal discomfort, incontinence, new-onset mental confusion, and loose stools. Her most current vital signs are 118/60, 88, 18, 98.4? F (36.9? C). The medical director ordered a postvoid catheterization, which yielded 100 mL of cloudy urine that had a strong odor, and several lab tests on admission. Urine culture and sensitivity (C&S) results are pending; the other results are shown in the chart.

Chart View

Laboratory Test Results

Complete metabolic panel (CMP): Within normal limits except for the following results:

BUN (7 to 20 mg/dL)

25 mg/dL (8.9 mmol/L)

Sodium(135 and 145 milliequivalents per liter (mEq/L).

131 mEq/L (131 mmol/L)

Potassium (3.6 to 5.2 millimoles per liter (mmol/L).

3.2 mEq/L (3.2 mmol/L)

White blood cell count (4,000 and 11,000 per microliter of blood)

11,000/mm3 (11 x 109/L)

Urinalysis

Appearance

Cloudy

Odor

Foul

pH

8.9

Protein

Negative

Nitrites

Positive

Crystals

Negative

WBCs

6 per low-power field

RBCs

3

1. What condition do the lab reports point toward?

 

2. Which assessment findings are typical of an older adult with the condition in Question 1?

  1. Fever
  2. Hematuria
  3. Bladder spasms
  4. Nonlocalized abdominal discomfort

3. Considering her history and laboratory results, what other condition is a possibility?

 

4. The medical director makes rounds and writes orders to start an IV of D5 NS at 75 mL/hr. Because M.Z. is unable to take oral medications, the medical director orders ciprofloxacin (Cipro) 400 mg q12h IV piggyback (IVPB). Are the type of fluid and rate appropriate for M.Z.’s age and condition? Explain.

 

5. While the IVPB ciprofloxacin is being administered, which adverse effects might occur? Select all that apply.

  1. Nausea
  2. Headache
  3. Drowsiness
  4. Hypotension
  5. Restlessness
  6. Tendon rupture

6. You enter the room to start the IV infusion and find that the UAP had taken M.Z. to the bathroom for a bowel movement. M.Z. asks you to help her, and, as you open the door, you observe her wiping herself from back to front. What do you need to during this time?

 

7. Later that day, M.Z. has difficulty voiding, and palpation of the bladder reveals distention. A bedside bladder scanner indicates at least 250 mL of urine in the bladder. A Foley catheter is ordered and inserted. Because M.Z. has been having diarrhea, what special instructions should you give the UAP assigned to give basic care to M.Z.?

CASE STUDY PROGRESS

The next day, you are the nurse assigned to M.Z.’s care. You notice that the UAP emptying the gravity drain is not wearing personal protection devices. You observe that the drainage port of the drainage bag was contaminated during the process because the UAP allowed it to touch the floor.

8. What issues need to be considered in protecting M.Z.’s safety? Describe your actions in working with the UAP.

 

9. As you assess M.Z., you notice that her catheter tubing is not secured. Why does the tubing need to be secured? Where is the correct place for the catheter tubing?

CASE STUDY PROGRESS

On the third day after M.Z.’s admission, the urinary C&S results are as follows: E. coli, more than 100,000 colonies, sensitive to ciprofloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin.

10. What changes, if any, will be made to the antibiotic therapy?

 

11. The UAP reports that M.Z.’s 8-hour intake is 520 mL and the output is 140 mL. Identify 2 possible reasons that could account for the difference and explain how you would assess each.

CASE STUDY PROGRESS

Further monitoring of M.Z.’s urine output reflects adequate output amounts. After a week, has completed her antibiotic therapy. Her mental status has cleared, the Foley catheter has been discontinued, and she is voiding without difficulty. She is ready for discharge.

 

12. What instructions should you discuss with the daughter?

 

13. She needs to notify the primary care physician if her mother develops which problems? Name at least 6.

  • Fever
  • Chills
  • Change in mental status
  • Decrease in urinary output not corresponding with intake
  • Increased pain on urination
  • Pain in the flank, suprapubic area, or abdomen
  • Foul-smelling urine
  • Blood or pus in the urine

CASE STUDY OUTCOME

The diarrhea subsides, and M.Z.’s urine is more clear and normal in appearance. She goes back to her daughter’s home after a week and is more alert.

Scenario # 2

You are working on a telemetry unit and have just received a transfer from the ICU. The 70-year-old male patient, T.A., is postoperative day 2 after three-vessel coronary bypass graft surgery. He has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus requiring insulin for the past 6 months to control glucose levels. The ICU nurse tells you that there were complications during surgery and he received 3 units of blood to treat hypotension. Since surgery, T.A. has experienced intermittent atrial fibrillation that is under control with amiodarone and metoprolol. The nurse voices concern his urine output seems to be decreasing.

 

1. Four hours after his admission to your floor, you note that T.A. has had a total urine output of 75 mL of dark amber urine. Why are you concerned?

 

2. You check the urinary catheter and tubing for obstructions and find none. What other assessments do you need to gather?

CASE STUDY PROGRESS

You notify the surgeon of the decreased urine output. The surgeon orders a stat electrolyte panel and asks you to call with the results.

Chart View

Laboratory Test Results

Potassium

5.8 mEq/L (5.8 mmol/L)

Sodium

132 mEq/L (132 mmol/L)

Glucose

224 mEq/L (12.4 mmol/L)

BUN

86 mg/dL (30.7 mmol/L)

Creatinine

4.4 mg/dL (389 mcmol/L)

3. Interpret T.A.’s laboratory results.

 

4. What actions do you need to take because of the serum potassium level?

CASE STUDY PROGRESS

Chart View

Medication Administration Record

Dopamine IV infusion at 2 mcg/kg/min
Furosemide 80 mg IV push daily
Sodium polystyrene sulfonate (Kayexalate) 1 gram PO twice daily
Sevelamer hydrochloride (Renagel) 800 mg PO with meals

5. The surgeon writes new orders. Identify the expected outcome associated with each medication he will be receiving.

  • Furosemide and low-dose dopamine are used to improve renal blood flow and maintain urine output. Furosemide will also increase the excretion of potassium.
  • Sevelamer hydrochloride is a dietary-phosphorus binding medication used to lower serum phosphorus levels.
  • Sodium polystyrene sulfonate increases potassium excretion by exchanging sodium for potassium ions.

6. T.A. weighs 164 lbs. The pharmacy-supplied IV bag reads “dopamine 400 mg/250 mL.” Calculate the hourly rate for the dopamine infusion. Round to the tenth.

 

CASE STUDY PROGRESS

The surgeon determines that T.A. is in the oliguric phase of acute kidney injury (AKI). T.A. is sent to radiology for placement of a dialysis catheter.

Image transcription text

Four phases of AKI This chart describes the features and durations of the four phases of acute kidney injury
(AKI). Phase Features Duration Onset phase . Common triggering events: Hours to days significant blood loss,
burns, fluid loss, diabetes insipidus . Renal blood flow 25% of normal Tissue oxygenation 25% of Show more
Show more

7. What is the likely reason T.A. developed AKI?

 

8. The RIFLE criteria delineate the three stages of AKI based on:

  1. Glomerular filtration rate (GFR)
  2. Serum creatinine and urine output
  3. Urine osmolality and specific gravity
  4. Blood pressure and BUN/creatinine ratio

9. You decide to assess T.A. for indications of AKI. What do these include?

 

10. What are your priority nursing problems right now?

 

11. The dialysis catheter is inserted into T.A.’s left subclavian vein. You are preparing to give the IV furosemide and find that his only other IV access, a peripheral line, is the site of the dopamine infusion. What are your options?

 

12. T.A. asks if he is going to be on dialysis for the rest of his life. How would you respond?

 

13. T.A. is placed on a fluid restriction and a renal diet. T.A. asks how much he is going to be able to drink. What is your reply?

 

14. Briefly describe a renal diet.

 

15. What referral may be needed and why?

 

16. What are some interventions you can use to help T.A. be more comfortable while on a fluid restriction?

 

17. As you plan your care of T.A. for the rest of the shift, identify which aspects of his care you can delegate to the UAP. Select all that apply.

  1. Measure vital signs every 2 hours
  2. Assist him with oral hygiene as needed
  3. Obtain T.A.’s glucose level before dinner
  4. Monitor T.A.’s lung sounds every 4 hours
  5. Obtain and record an accurate daily weight
  6. Evaluate T.A.’s I/O trends for the past 48 hours

18. You note that T.A.’s postoperative blood glucose levels range from 62 to 387 mg/dL (3.4 to 21.6 mmol/L). He comments, “That’s funny, you’re giving me almost twice the amount of insulin that I give myself at home. I don’t understand why it’s not working.” How should you respond?

 

19. In addition to ongoing assessment, describe nursing interventions to place in T.A.’s plan of care that are part of patient safety initiatives aimed at minimizing his risk for a VTE developing.

CASE STUDY PROGRESS

The next morning, T.A. is scheduled for his first dialysis treatment at 0800.

20. What type of assessment data do you need to gather before his dialysis treatment?

 

21. Doses of IV amiodarone, metoprolol, and furosemide are scheduled for 0800. What should you do?

  1. Give all three medications 1 hour before dialysis
  2. Hold all three medications and notify the surgeon
  3. Give the amiodarone and hold the metoprolol and furosemide
  4. Hold all three medications and give them immediately upon return

22. T.A. is off the unit 4 hours for therapy. When he returns, what assessments do you need to make?

 

23. Shortly after his return, T.A. tells you he has a headache and severe nausea. He is restless and slightly confused, and his BP is 180/102 mm Hg. What is the significance of these findings?

 

24. You page the surgeon. What will you do while waiting for a return call?

CASE STUDY OUTCOME

T.A. recovers from the episode of disequilibrium syndrome. During the rest of his hospitalization, he continues to have trouble maintaining fluid and electrolyte balance between his dialysis treatments. He spends two weeks in a rehabilitation center before being discharged on dialysis and with home health. He eventually regains kidney function.