Question

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 non- localized abdominal pain, incontinence, new-onset mental confusion, and loose stools. Her most current vital signs are 118/60, 88, 18, 98.4° F (37.4° C). The medical director ordered a post void catheterization, which yielded 100mL of cloudy urine that had a strong odor, and several lab tests on admission. Urine culture and sensitivity results are pending; the other results are shown in the chart.

Chart View Laboratory Test Results:

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

BUN 25mg/dL Sodium 131mEq/L

Potassium 3.2mEq/L

White blood cell count 11,000/mm3

Urinalysis Appearance Cloudy Odor Foul

pH 6.9

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?
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 ½NS at 75mL/hr. and insert a Foley catheter to gravity drainage. Because M.Z. is unable to take oral medications, the medical director orders ciprofloxacin (Cipro) 400mg 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?

6. You enter the room to start the IV infusion and insert the Foley catheter and find that the nursing assistive personnel (NAP) has 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 do at this time?

7. Because M.Z. has been having diarrhea, what special instructions should you give the NAP 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 NAP emptying the gravity drain is not wearing personal protection devices. You also observe that the drainage port of the drainage bag was contaminated during the process because the NAP 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 nursing assistant.

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

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

Answer 1

1 Possible diagnosis is a Urinary Tract Infection.

2 Assessment findings typical of an older adult is the new-onset of mental confusion (UTI in elderly adults causes confusion)

Other assessments pointing to the diagnosis include:-

*White blood cell count 11,000/mm3

*Presence of Nitrites in urine

*Urinalysis Appearance Cloudy Odor Foul

*Urinary retension (post void catheterization yielded 100ml urine)

*Urinary Incontinence (is a non clasic sign of UTI)

3 Other possible diagnosis can be a pyelonephritis.

4 Treatment of UTI:

Rehydration with IV fluids are essential, as it help to flush out the remaining bacteris.

Antibiotics are the treatment of choice for UTI.

Usually used antibiotics are amoxicillin and nitrofurantoin.

Ciprofloxacin and Levofloxacin are broad spectrum antibiotcs used to treat severe infections.

Taking into consideration, her age and the severity of infection, the prescribed treatment is appropriate.

5 Possible Sie effects of Ciprofloxacin are:-

Nausea & Vomiting

Heartburn

Diarrhoea

Abdominal Pain

Fatigue (unusual tiredness)

Pale skin

Vaginal itching and/or discharge

Genaral Care

***Wiping back to front causes the bacterial load (incliding E.coli) around the anal orifice to reach the urethral orifice which worsens the infecton. All women should be advised to wipe front to back.

Care of Indwelling Foley's Catheter

1 The gravity dran should be emptied hourly and the output should be measured. It should never be allowed tp be overfilled, as it cause backflow of the uine.

2 The tip of the drain should never touch the floor or the container that its being emptied into. It causes contamination

3 Care takers should always use gloves while emptying the urine. This reduces the risk of cross infecton.

4 Tubings should be secured on the thighs to prevent pulling and accidental displacement.

5 The drainage bag should never be lifted above the hip level to prevent backflow.