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Disorders of the urinary system.

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:

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

Full Answer Section

Urinary tract infection (UTI): The cloudy urine raises suspicion for a UTI, which can cause confusion, especially in elderly patients.
Underlying medical conditions: Mabel's comorbidities like diabetes, hypertension, atrial fibrillation, and rheumatoid arthritis can contribute to confusion, especially when poorly controlled.

What pivotal decision in the ER directly caused Mabel's worsening condition?

It's difficult to pinpoint one specific decision in the ER as the sole cause of Mabel's worsening condition. However, the insertion of a Foley catheter without addressing the underlying cause of her incontinence might have contributed to her decline. Catheters can increase the risk of UTIs, which can worsen confusion and delirium in elderly patients.

What type of incontinence did Mabel have?

Mabel's initial report of "weakness" to get to the bathroom and experiencing bouts of incontinence suggests she had urinary urgency and frequency, possibly with overflow incontinence. This means she felt a strong need to urinate frequently but couldn't hold her urine until she reached the bathroom, leading to leakage.

What factors in Mabel's medical history contributed to her change in condition?

Several factors in Mabel's medical history could have contributed to her decline:

Diabetes: Poorly controlled diabetes can lead to complications like UTIs, dehydration, and confusion.
Hypertension: Uncontrolled high blood pressure can affect blood flow to the brain, potentially contributing to confusion.
Atrial fibrillation: This irregular heartbeat can increase the risk of blood clots, which could have been a contributing factor to her sudden change in condition.
Rheumatoid arthritis: Chronic pain and fatigue from this inflammatory condition can affect overall well-being and potentially contribute to confusion.

How did communication (or lack thereof) contribute to the poor outcome for Mabel?

Communication plays a crucial role in patient care, and several aspects could have been improved in this case:

Limited communication with the long-term-care facility: More information about Mabel's baseline mental status and recent episodes of confusion could have helped healthcare providers in the hospital better understand and address her condition.
Delayed notification of changes in condition: The RN wasn't notified immediately about Mabel's confusion on the evening of the 16th, potentially delaying a more thorough evaluation and intervention.
Lack of clarity about Mabel's daughter's concerns: The daughter's concerns about a possible stroke and Mabel's "feeling warm" weren't fully investigated, potentially missing a critical clue about her worsening condition.

Overall, Mabel's case highlights the complex interplay of various factors in causing and exacerbating confusion and delirium in elderly patients. While pinpointing a single cause is challenging, improved communication, comprehensive assessments, and timely interventions could have potentially prevented her tragic outcome.

Sample Answer

Mabel's confusion and combativeness could be attributed to a combination of factors:

Fluctuations in blood sugar: Mabel's recurrent hypoglycemia, evidenced by the low finger sticks, could have triggered episodes of confusion due to the brain's dependence on glucose for proper functioning.
Dehydration: The Foley catheter draining clear yellow urine initially suggests adequate hydration, but the cloudy urine later could indicate dehydration, which can also contribute to confusion and delirium.
Medications: Some of Mabel's medications, like Furosemide (a diuretic) or Warfarin (a blood thinner), can have side effects like dizziness and confusion, especially in older adults.