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Student Name:
Rachelle Johnson
Primary Diagnosis:
Sepsis from UTI
Co-morbidities:
C-Diff, Hypokalemia, Acute renal failure, PCM Severe, Chronic kidney disease stage 4, AFib, UTI
Hypertension, BPH with urinary retention, Candiduria, nephrolithiasis, osteoarthritis,
failure to thrive, restless leg syndrome, onychomycosis
Discharge Plan (add day of clinical):
Home with hospice when C-Diff subsides
Integrated Pathophysiology (what is going on with your patient at the cellular level for the health
condition, no more than three pages in length, including reference page)
My patient is a ninety-three year old male presenting to MCU for sepsis related to a UTI. His wife
brought him to the ED with progressively worse weakness. He was admitted for sepsis due to a UTI. Sepsis is a
condition that cannot occur on its own it must start with some kind of infection such as a UTI like my patient
had. It is an infection that begins with bacteria, a virus or fungi. It occurs when bacteria enters the bloodstream
and produces bacteremia. The bacteria can stimulate the inflammatory response or release toxins into the
bloodstream.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular
IV (Fluid type, rate, access type):
Central line
Right femoral SL
CBG (Yes/No, frequency): No
Activity (What is ordered): 1-2 assist with PT
Oxygen (Yes/No, Delivery method, how much):
Standing order 1-4L NC to keep 02 about
93%
Last BM: 2-9-15
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Weeping skin all over body weeping
edema? Skin moist? Diaphoretic?
Abrasion L upper arm
Abrasion R upper back covered- Clean, dry,
intact dressing
Ecchymosis spread all over body
Amputated L third finger
No tenting
Nails-Thick
Skin temp?
Texture?
Turgor?
Ear/Nose/Throat:
Ear- No drainage, HOH
Nose- Bloody drainage, dry mucous
membranes
Throat & Mouth- Dry, own teeth, missing
back teeth
No difficulty swallowing
Eyes?
Cardiac:
Cap refill less than 3 seconds where?
S1 & S2 heard regular? Irregular?
No JVD
No murmur, gallop
A-Fib how do you know?
+2 bilat radial & pedal pulses regular?
Irregular?
Edema 1+ hands, no lower extremity
edema
Genitourinary:
Tea colored urine
Incontinent & Continent
Voided 150mL
No odor, pain or burning
UTI hx
Neurological:
A&O x 2 not oriented to time
No facial droop
Clear speech
PERRLA
Face symmetrical
Thorax/Lungs:
Diminished LLQ & RLQ lungsanterior?
Posterior?
Clear upper & middle quadrants lungs have
lobes not quadrants
No cough
SOB upon turning & activity
Respirations labored 16 breaths per minute
Respiratory effort?
Chest expansion?
Musculoskeletal:
Generalized weakness muscle strength
___/5
1-2 assist with PT
Full ROM where?
Turns self in bed
Did not get up for me
Gastrointestinal:
Normoactive bowel sounds where?
Last BM 2-9-15
Distended non tender
Incontinent of bowel?
Soft- no palpable masses
C-Diff
Other (Include vital signs, weight):
BP: 129/66
P: 85
R: 16
O2: 97%
T: 97.4
Demeanor?
Weight- 66.7kg
Height 67.99 Inches
CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name
Dose/Route
/
Rate if IV
Clasiisficatio
n
Onset/Peak
Chest Heparin
Flush
30 Unit=3mL
IV PRN
Anticoagulants
O: Immediate
P: 5-10 min
D: 2-6 hr
Chest Saline
Flush (Sodium
Chloride Flush)
10 ML IV
PRN
Bifantis
(Align)
4mg 1 Cap PO
Daily
Mineral
Electrolyte
Replacement
Isotonic
Probiotic
Herbal
supplement
Chlorhexidin
e 0.12% oral
rinse
(Peridex
0.12%)
15mL BID
Swish and
Spit
Chlorhexidin
e 4%
(hibiclens
4%)
Flagyl
(Metronidazole)
Mupirocin 2%
Ointment Nasal
(Bactroban)
Pantoprazole IV
(Protonix IV
Push)
Prednisone
Intended
Action/Therapeutic
use. Why is this
client taking med?
Anticoagulant to prevent
clots
Adverse reactions
(1 major side
effect)
Bleeding
O: Unk
P: Unk
D: Unk
Used to Flush IV
Redness
O: Unk
P: Unk
D: Unk
Restoration of intestinal
flora
Bloating
Anti-septic
AntiMicrobial
O: Unk
P: Unk
D: Unk
Gingivitis
Mouth Irritation
1
application
topical
daily
Anti-septic
AntiMicrobial
O: Unk
P: Unk
D: Unk
Skin Irritation
500mg/NS
100mLQ8
AntiTrichomonal
Amebicide
HL: 25-75h
O: rapid
P: 1-3h
Fungal infection
Vertigo
Anti-infective
O: unk
P: unk
D: 12 hr
Skin infection
Burning, stinging
2% Ointment
Nasal 1g =
1g nasal BID
40mg = 10mL
IV push daily
Antiulcer
agents/
Gastric proton
pump inhibitor /
Anti-secretory
O: 2.5 hr
P: unk
D: 1 wk
GERD
Diarrhea
10mg a day,
1tab
Adrenal
corticosteroid
Peak 1-2h
Half life 3.5h
Has an anti-inflammatory
and immunosuppressant
property.
Hypoglycemia
Vancomycin
(Vancocin Oral)
125mg = 1
cap PO Q6H
Antibiotic;
glycopeptide
Acetaminophen
(Tylenol)
650mg = 2
tabs PO Q4H
PRN headache
Pain Reliever/
Antipyretic
Peak 30min
: 4-8h
Hypotension
accompanied by
flushing and
erythematous rash on
face and upper body
O: w/in 1H P:0.52H
Pain reliever
Elevation of
ALT/AST
Ondansetron
Injection
(Zofran
Injection)
4mg = 2mL
IV Q4H prn
nausea/
vomiting
Antiemetic
O: rapid
P: 15-30m
HL:3.5-5.5h
dizziness, drowsiness,
constipation, diarrhea
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [Xrays, CT, MRI, U/S, etc.]
Date
Lab Test
Normal
Values
Patient Values/
Date of care
2-915
Sodium
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
139
NA
5.3
Chloride
97-107 mEq/L
119
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
16
134
62
Creatinine
0.5 1.2 mg/dL
2.07
NA
NA
8.0
NA
NA
1.6
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
5.0
Albumin
3.4-4.8gm/dL
2.4
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
NA
NA
42
NA
35
NA
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x
10
female: 4.2-4.87 x
10
HGB
male: 12.6-17.4
g/dL
female: 11.7-16.1
g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
NA
NA
NA
NA
10.8
NA
3.02
8.7
25.5
85
28.9
NA
34.3
NA
14.8
NA
157
NA
DIAGNOSTIC TESTING
Date
UA
2-715
Color/Appearan
ce
pH
Spec Gravity
Protein
Normal
Range
5-8
1.0051.030
Neg
Results
Interpretation as related to
Pathophysiology cite
reference & pg #
Red
7
1.005
NA
NA
3+
Glucose
Ketones
Neg
Neg
Neg
Trace
NA
Ketones in the urine indicate fat
being used as a main source of
energy. This can be d/t starvation or
fasting, my pt has not been
Blood
Date
Other
Date
2-9-15
4+
Normal
Range
Results
INR
0.9-1.1
1.4
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
2-915
NegTrace
Radiology
ABDOMEN
(KUB)
Scans
EKG-12 lead
Telemetry
Results
Interpretation as related to
Pathophysiology cite
reference & pg #
NA
NA
NA
NA
NA
NA
NA
Interpretation as related to
Pathophysiology cite
reference & pg #
No evidence of
obstruction, no gross
ascites, mult calcifications
in the pelvis consistent
with phleboliths.
NA
NA
NA
NA
NA
NA
NA
2-10-15 1735- Pt reporting no pain, VS- 97.4, 129/66, P: 85, R: 16, O2: 97%,
normoactive bowel sounds where?. Administered vancomycin, educated pt
on side effects & to take it with food. Pt shook head in understanding,
swallowed pill with out difficulty, set up tray for dinner, call light & fluids with
in reach.
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as
evidenced by (AEB).
Problem #1 Fluid volume deficit r/t active fluid volume loss AEB diarrhea what other
evidence supports thisuse more than 1
Desired Outcome: Maintain adequate fluid intake AEB moist mucous membranes & with
vital signs remaining: Pulse between 60-100, BP between 90-119/60-79)what is
adequate? 1 cup? 64 oz?
Nursing Interventions
Client Response to Intervention
1. Provide 100mL of fluid every hour
1. Pt enjoyed fluids & gladly took
drinks when offered
2. Assess VS & Mucous membranes every 4
2. Pt was cooperative with frequent
hours
checks
3. Assess pts preference on different fluid
choices at beginning of shift
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Pt was cooperative; he enjoyed drinking & was always accepting of any fluids I offered
him. His vitals remained between designated ranges; however, his mucous membranes
remained dry. He was not hooked up to any IV fluids and appeared to be dehydrated.
Problem #2 Impaired urinary elimination r/t weak sphincter AEB urinary incontinence &
urgency
Desired Outcome: Demonstrate urinary elimination twice during shift
Nursing Interventions
1. Assess pts ability to sense ability to urinate
every 2 hours
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
Pt used urinal often with small amounts of urine; however, also was incontinent at times
when not able to get gowned up quick enough. Never used call light but would call out at
first sign of urgency. Educated pt on call light use; however, pt was forgetful so could not
properly use it. Instead I sat outside his door so I could hear when he woke up. Do you
think his dehydration played a role in his voiding pattern
Problem #3 Impaired skin integrity r/t moisture AEB incontinence
Desired Outcome: Keep skin clean, dry, & intact without redness
Nursing Interventions
Client Response to Intervention
1. Change pt promptly after elimination &
1. Checked pt every 2 hours & changed
perform peri care
brief & did pericare each time
incontinent. Pt cooperative & willing to
let me help.
2. Reposition pt every 2 hours
2. Pt was self moving
3. Apply barrier skin to patients bottom every
time changed
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
Kept pt clean & dry throughout shift with frequent hourly checks. Pt was able to self-turn
& reposition himself. Cooperative with pericare as well as barrier protection.
My patient is a ninety-three year old male presenting to MCU for sepsis related to a UTI.
His wife brought him to the ED with progressively worse weakness. He was admitted for sepsis
due to a UTI. Sepsis is a condition that cannot occur on its own it must start with some kind of
infection such as a UTI like my patient had. It is an infection that begins with bacteria, a virus or
fungi. It occurs when bacteria enters the bloodstream and produces bacteremia. The bacteria can
stimulate the inflammatory response or release toxins into the bloodstream.
A urinary tract infection is an infection caused by bacteria in the urinary epithelium. The
most common site for a UTI is in the bladder, also known as acute cystitis. With advanced
inflammation in the bladder, blood is common; my patient has been experiencing blood in his
urine, which could be due to this reason from the UTI. The most common types of bacteria
associated with urinary tract infections include, Escherichia coli and Staphylococcus
saprophyticus. The retrograde movement of gram- negative bacilli in the urethra and balder and
then the ureter and kidney is how the normally sterile urine is contaminated with the bacteria
(Huether & McCane 2012). The elderly have the highest risk factor to UTI, my patient fits in to
this category. The elderly often times show confusion along with aggression and can be the only
symptom that they show. Recurrent UTIs affect my patient and can increase his risk of mortality.
A urinary tract infection interferes with my patients life, he is experiencing incontinence
most like due to the UTI as well as incontinence of stool due to his diagnosis of c-diff. This can
put him at a severe risk for skin integrity from constant moisture and irritation on his buttock and
perennial area. My patient is on vancomycin to help treat his infections and help with his sepsis
and prevent septic shock. It is important to educate my patient on continuing his antibiotics for
the entire course they are ordered and taking them the same time every day to prevent antibiotic
resistance.
References:
Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo.:
Mosby/Elsevier.