Nursing interventions for clients with disorders of the urinary system.

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Select appropriate nursing interventions for clients with disorders of the urinary system.

Instructions
You are an LPN working on a medical-surgical floor in a team that consists of an RN and a medical assistant. Read through some of the chart entries over a 48-hour period and answer the questions at the end. Please make sure you cite any sources using APA format. You will find when there is a major clue.

0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence.

600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor:
0730: (RN) Report is given to RN on 3 North.

Emergency Department Chart

Client: Mabel Simpson
DOB: 4/23/1941
Admission Date 8/16/2019
Medical Diagnosis: recurrent hypoglycemia
Allergies: None

Vitals/ Data Collection: Temp.- 97.3 PO
History: Diabetes (insulin dependent)
Medications: Insulin R titrated to finger sticks
Allergies: None

Vitals/ Data Collection: Pulse- 68
History: Hypertension
Medications: Furosemide 20 MG twice per day
Allergies: None

Vitals/ Data Collection: Respirations- 18
History: Atrial Fibrillation
Medications: Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs
Allergies: None

Vitals/ Data Collection: Blood Pressure- 122/86
History: Rheumatoid Arthritis
Medications: Enalapril 5 Mg once per day
Allergies: None

Vitals/ Data Collection: No C/O pain
History: Mild Heart Failure (class 1)
Medications: Proventil inhaler as needed for wheezing
Allergies: None

Vitals/ Data Collection: Alert and oriented X 4
History: Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago
Medications: Methotrexate 2.5 Mg per day
Allergies: None

Vitals/ Data Collection: Lungs: No adventitious sounds
History: Appendectomy as a child
Medications: Tylenol 650 Mg as needed for pain or fever
Allergies: None

Vitals/ Data Collection: + Bowel sounds
History: Mobility (baseline): able to ambulate slowly with minimal assist
Clear yellow urine draining from Foley catheter in adequate amts.
Medications:
Allergies: None

Vitals/ Data Collection: Clear yellow urine draining from Foley catheter in adequate amts.
History:
Medications:
Allergies: None

8/16/2019
10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.

8/17/2019 (Medical Assistant)
0130: Sleeping Soundly

0700: (LPN) alert and oriented Finger stick 124. Offering no complaints. Medications given as ordered. Foley catheter draining cloudy yellow urine- RN notified.

1100: (Case Manager note): Pt. alert and oriented. Blood sugar stable. Will speak to the physician about discharge tomorrow morning.

1300: (Physical Therapy): Ambulated to the hallway 200 feet. Ambulates slowly- baseline as per long-term-care facility charge nurse. Recommend physical therapy after discharge, however, ambulated well enough for discharge.

1600: (LPN) Pt found to be confused (alert and oriented X 1). RN notified. Fingerstick 130. Vitals 97.5 (axillary), 110, 24, 98/64

1800: (Medical assistant) 400 cc’s emptied from catheter bag.

0100: (RN) Pt confused and combative. Attempting to pull out her IV and repeatedly removing her gown. Pt’s physician was paged- ordered Lorazepam 1 MG IM. Medicated as ordered and slept the remainder of the night with no incident.

0700: (RN) Pt awake and alert but combative. Finger stick-124. Vitals: 98.9 (axillary), 116, 28, 90/55

1730: (LPN) Unable to administer medication. Pt appears extremely confused. RN notified.

1200: (LPN) Pt’s daughter at bedside. Daughter indicates that her mother is not normally confused and is concerned that she may have had a stroke and notes that her mom feels “very warm.” RN notified. Foley catheter draining cloudy urine.

1230: (Medical Assistant) Vital signs: T 103.6 (rectal), P=130, BP=84/43, resp rate=28

1300: (RN) Rapid response called (because of the change in condition) and client transferred to the ICU.

Update: The client spent 3 days in the ICU but unfortunately did not recover.

Please answer the following questions:
1. Why did this client become confused and combative? (5-10 sentences)
2. What pivotal decision made in the ER directly caused this client’s worsening condition? (1-2 sentences)
3. What type of incontinence did this client have? Explain your answer. (5-10 sentences)
4. What factors in the client’s medical history contributed to the client’s change in condition? (5-10 sentences)
5. How did communication (or lack thereof) contribute to the poor outcome for this client? (5-10 sentences)

Format
• Standard American English (correct grammar, punctuation, etc.)
• Logical, original and insightful
• Professional organization, style, and mechanics in APA format
• Submit document through Grammarly to correct errors before submission

 

Sample Solution

1. Cause of Confusion and Combativeness: Several factors likely contributed to Mabel’s confusion and combativeness:

  • Hypoglycemia: Recurrent hypoglycemia can lead to altered mental state, confusion, and agitation. Her fluctuating blood sugar levels, initially high and then dropping throughout the day, suggest potential mismanagement of her diabetes.
  • Urinary Tract Infection (UTI): The cloudy urine noted on the 17th and 1200 on the 18th, along with fever (1230) and rapid response call (1300), suggest a possible UTI. UTIs can cause confusion and delirium, especially in older adults.
  • Medications: Certain medications, like Warfarin and Lorazepam, have side effects that can include confusion and agitation. Interactions between her multiple medications may also be a factor.
  • Dehydration: Dehydration can worsen confusion and complicate UTIs. Her medications (diuretic) and recurrent hypoglycemia could both contribute to dehydration.
  • Underlying medical conditions: Mabel’s age, comorbidities like atrial fibrillation, and potential cognitive decline due to Rheumatoid Arthritis increase her vulnerability to delirium and confusion.

2. Pivotal Decision in the ER: Placing a Foley catheter directly caused Mabel’s worsening condition. While incontinence can be a symptom of a UTI, unnecessary catheterization increases the risk of introducing bacteria and causing UTIs, especially in vulnerable populations like older adults.

3. Type of Incontinence: Mabel’s incontinence was likely overflow incontinence. This occurs when the bladder becomes overfull and leaks urine involuntarily. It can be due to weak bladder muscles, neurological problems, or medications that increase urine production. In Mabel’s case, her medications (diuretic) and potentially uncontrolled diabetes could contribute to bladder overactivity and overflow incontinence.

4. Factors Contributing to Worsening Condition:

  • UTI: The possible UTI, likely caused by catheterization, led to infection and systemic inflammatory response.
  • Hypoglycemia: Fluctuating blood sugar levels can destabilize the brain and exacerbate confusion, contributing to falls and further decline.
  • Dehydration: Dehydration from diuretics, hypoglycemia, and potential lack of oral intake likely worsened her confusion and compromised vital organ function.
  • Multiple co-morbidities: The interplay of her pre-existing medical conditions, like atrial fibrillation and Rheumatoid Arthritis, alongside age, compounded the effects of acute issues like UTI and hypoglycemia.

5. Role of Communication in Poor Outcome:

  • Delayed recognition of UTI: Lack of communication between caregivers, nurses, and physicians regarding the cloudy urine and fever delayed diagnosis and treatment of the UTI, allowing it to progress and worsen her condition.
  • Insufficient attention to blood sugar control: Fluctuating blood sugar levels weren’t adequately addressed, potentially contributing to her confusion and exacerbating other issues.
  • Communication gaps with family: The daughter’s concerns about a stroke were not fully investigated, potentially missing a neurological cause for her decline.

Overall, Mabel’s case highlights the importance of holistic assessment, considering all factors from pre-existing conditions to potential infections and medication interactions. Timely diagnosis and interventions for infections, managing chronic conditions effectively, and open communication across all care providers and with the family are crucial to avoid such tragic outcomes.

Note: This analysis is based on the provided information and does not constitute a professional diagnosis or medical advice. It is important to consult with healthcare professionals for any medical concerns.

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