A patient with a history of recurrent UTIs presents with symptoms suggestive of pyelonephritis. Which nursing intervention is the most critical to perform immediately to prevent complications?

C) Initiate intravenous antibiotic therapy promptly.

A) Administer oral antibiotics as prescribed.

B) Encourage the patient to increase fluid intake to flush out the bacteria.

C) Initiate intravenous antibiotic therapy promptly.

D) Apply a warm compress to the patient's abdomen to alleviate pain.

A patient with a history of recurrent urinary tract infections presents with suprapubic tenderness, flank pain, and fever. The urinalysis shows significant leukocyte esterase and nitrites. Given the patient's allergy to penicillin, which nursing intervention is most appropriate to prioritize while awaiting urine culture results?

B) Initiate intravenous ciprofloxacin and monitor the patient's vital signs.

A) Administer oral trimethoprim-sulfamethoxazole and encourage fluid intake.

B) Initiate intravenous ciprofloxacin and monitor the patient's vital signs.

C) Provide acetaminophen for fever and delay antibiotics until culture results are available.

D) Start oral nitrofurantoin and instruct the patient on proper perineal hygiene.

A patient receiving intravenous antibiotic therapy for a urinary tract infection exhibits a sudden spike in temperature, tachycardia, and hypotension. Blood cultures identify a multi-drug resistant organism, prompting a change in antibiotics. What is the nurse's priority intervention to address the patient's condition?

C) Initiate aggressive fluid resuscitation

A) Administer antipyretics to reduce the fever

B) Increase the frequency of vital sign monitoring

C) Initiate aggressive fluid resuscitation

D) Educate the patient about the new antibiotic regimen

A nurse is caring for a patient who has shown signs of septic shock after 48 hours of antibiotic therapy for a urinary tract infection. The patient's vital signs include a temperature of 39.5°C (103.1°F), heart rate of 120 beats per minute, and blood pressure of 90/60 mmHg. Given the recent identification of a multi-drug resistant organism in the patient's blood cultures, what is the nurse's priority action?

A) Initiate aggressive fluid resuscitation to manage hypotension.

B) Administer antipyretics to reduce the patient's fever.

C) Notify the physician immediately to discuss the change in antibiotics.

D) Place the patient on oxygen therapy to improve tissue perfusion.

A patient with a severe urinary tract infection caused by a resistant strain of Escherichia coli is experiencing hypotension, oliguria, and altered mental status despite antibiotic therapy and fluid resuscitation. Which nursing intervention is the priority at this time?

D) Notify the healthcare provider to discuss the possibility of transferring the patient to intensive care.

A) Increase the rate of fluid administration to improve blood pressure and perfusion.

B) Monitor the patient's neurological status closely for further signs of deterioration.

C) Prepare the patient for a head CT scan to evaluate potential neurological complications.

D) Notify the healthcare provider to discuss the possibility of transferring the patient to intensive care.

A patient with a confirmed resistant strain of Escherichia coli is being monitored closely due to signs of sepsis, including hypotension, fever, and oliguria. Despite aggressive fluid resuscitation, the patient's blood pressure remains low, and they begin to exhibit altered mental status. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Prepare for the initiation of vasopressor therapy

A) Increase the rate of fluid resuscitation to improve blood pressure

B) Prepare for the initiation of vasopressor therapy

C) Administer antipyretics to reduce fever

D) Increase monitoring of urine output every hour

A patient with sepsis and worsening renal function is undergoing continuous venovenous hemofiltration (CVVH). The nurse is monitoring the patient's hemodynamic status, urine output, and mental status. Which finding would indicate that the current treatment plan is effective?

B) Urine output increases to 50 mL/hour

A) Blood pressure remains at 88/55 mmHg without changes

B) Urine output increases to 50 mL/hour

C) The patient becomes more lethargic and confused

D) Creatinine levels continue to rise

A patient with sepsis and worsening renal function has been initiated on continuous venovenous hemofiltration (CVVH) and low-dose norepinephrine infusion. Which clinical assessment finding would indicate an improvement in the patient's condition?

A) Decreased blood pressure to 80/50 mmHg

A patient undergoing continuous venovenous hemofiltration (CVVH) with persistent altered mental status despite hemodynamic stabilization is found to have blood cultures positive for ESBL-producing E. coli. What is the most appropriate nursing action in response to the infectious disease specialist's recommendation to switch to a carbapenem antibiotic?

A) Administer the prescribed carbapenem and monitor for signs of improvement in mental status.

B) Continue with the current antibiotic regimen and report any changes in vital signs.

C) Hold all antibiotics until further clarification from the healthcare provider.

D) Increase the rate of CVVH to enhance clearance of metabolic byproducts.

A patient undergoing continuous venovenous hemofiltration (CVVH) and vasopressor support for septic shock with ESBL-producing E. coli bacteremia is noted to have persistent altered mental status. Which nursing intervention is most appropriate to address this clinical finding?

A) Increase the frequency of neurological assessments to monitor for changes.

B) Administer a sedative to help improve the patient's comfort level.

C) Reduce the rate of CVVH to prevent further metabolic disturbance.

D) Discontinue vasopressor support to allow for improved cerebral perfusion.

uti - Nursing Case Study

Pathophysiology

• Primary mechanism: Urinary Tract Infections (UTIs) most commonly result from bacterial invasion, particularly by Escherichia coli, which ascend the urethra to colonize the bladder, causing inflammation and symptoms like dysuria and frequent urination.

• Secondary mechanism: The bacteria's ability to adhere to the uroepithelium via fimbriae facilitates persistent infection and evasion of the host's immune response, leading to a continued inflammatory cycle and potential progression to the kidneys.

• Key complication: If untreated, UTIs can ascend to the kidneys, causing pyelonephritis, which is characterized by fever, flank pain, and potential risk of systemic infection (sepsis), requiring prompt intervention to prevent renal damage.

Patient Profile

Demographics:

32-year-old female, office manager

History:

• Key past medical history: Recurrent urinary tract infections, hypertension

• Current medications: Lisinopril, cranberry supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe lower abdominal pain

• Key symptoms: Burning sensation during urination, increased frequency and urgency, fever, chills, flank pain

• Vital signs: Temperature 101.3°F, heart rate 110 bpm, blood pressure 145/92 mmHg, respiratory rate 20 breaths per minute

Section 1

During the initial assessment, the clinical team noted that the patient appeared visibly uncomfortable, with her hand placed protectively over her lower abdomen. On physical examination, there was notable tenderness upon palpation of the suprapubic region, and the patient reported exacerbated pain with pressure. Additionally, flank tenderness was elicited upon percussion, suggesting possible renal involvement. Upon further questioning, the patient mentioned having experienced similar symptoms in the past but noted that the pain and discomfort were more intense this time, coupled with a persistent fever.

Given the patient's clinical presentation and past medical history of recurrent UTIs, the healthcare provider ordered a urinalysis and urine culture to identify the causative organism and determine antibiotic sensitivity, given her penicillin allergy. The urinalysis revealed cloudy urine with significant leukocyte esterase and nitrites, indicating a bacterial infection. Microscopic analysis showed abundant white blood cells and occasional red blood cells, further supporting a diagnosis of a complicated urinary tract infection. Blood tests showed elevated white blood cell count and C-reactive protein levels, indicative of a systemic inflammatory response.

Recognizing the potential complication of pyelonephritis, the clinical team decided to initiate intravenous antibiotics, opting for a broad-spectrum agent to cover gram-negative bacteria, while awaiting culture results. The patient's vital signs continued to be closely monitored, as her elevated temperature and heart rate were concerning for potential progression to sepsis. This careful monitoring and prompt intervention were critical to prevent further complications, such as acute kidney injury or systemic infection, which could significantly impact the patient's recovery and overall health.

Section 2

As the clinical team continued to monitor the patient, they observed that her condition showed signs of improvement initially, with a slight reduction in fever and a decrease in flank pain after 24 hours of intravenous antibiotic therapy. However, by the second day of treatment, the patient's condition began to deteriorate unexpectedly. Her temperature spiked to 39.5°C (103.1°F), and she became increasingly tachycardic, with a heart rate rising to 120 beats per minute. Additionally, her blood pressure dropped to 90/60 mmHg, raising concerns about the development of septic shock. The patient also reported new onset of nausea and vomiting, coupled with increased fatigue, suggesting a worsening systemic infection.

Given these alarming changes in the patient's status, the clinical team promptly reassessed her condition. A repeat urinalysis and blood cultures were ordered to evaluate the effectiveness of the current antibiotic regimen and to check for any new or resistant pathogens. The repeat urinalysis still showed significant bacteriuria and pyuria, consistent with ongoing infection. Blood cultures revealed the growth of a multi-drug resistant organism, necessitating a change in the antibiotic regimen. The decision was made to switch to a more targeted antibiotic, specifically effective against the identified pathogen, and to initiate aggressive fluid resuscitation to address her hypotension.

These developments required a coordinated response from the healthcare team, emphasizing the importance of vigilant monitoring and timely interventions to prevent further complications. The patient's care plan was adjusted to include more frequent vital sign checks, continuous cardiovascular monitoring, and regular assessments of renal function to detect any early signs of acute kidney injury. This comprehensive approach aimed to stabilize the patient and prevent the progression of sepsis, thereby facilitating her recovery and minimizing the risk of long-term complications.

Section 3

As the clinical team implemented the revised care plan, they continuously monitored the patient's vital signs and response to the new antibiotic therapy. Within the first 12 hours of intervention, the patient's heart rate showed a slight improvement, decreasing to 110 beats per minute, while her blood pressure remained concerning at 92/58 mmHg despite aggressive fluid resuscitation. The patient's temperature, however, remained elevated at 38.9°C (102°F), indicating persistent infection and an ongoing inflammatory response.

Lab results from the repeat blood cultures confirmed the presence of a resistant strain of Escherichia coli, which was known for causing severe urinary tract infections and had shown susceptibility to only a limited class of antibiotics. The team also noted a rising creatinine level of 1.9 mg/dL, up from 1.1 mg/dL at admission, suggesting the onset of acute kidney injury likely due to both the systemic infection and the hypotensive episodes. Urine output was closely monitored, revealing oliguria with output decreasing to 20 mL/hr, further indicating compromised renal function.

Despite the change in antibiotic therapy and fluid management, the patient began to exhibit signs of mental status changes, becoming more lethargic and disoriented. This altered mental status prompted an urgent evaluation for potential central nervous system involvement or worsening sepsis. The clinical team prioritized a head CT scan to rule out any neurological complications and prepared for the possibility of escalating to intensive care support if the patient's condition failed to stabilize. These developments underscored the critical need for continuous reevaluation and adaptation of the treatment plan to address both the immediate and potential systemic complications of the infection.

Section 4

As the patient's condition continued to evolve, the clinical team received the results from the head CT scan, which fortunately showed no acute intracranial abnormalities. However, the neurologist on call was consulted due to the persistent altered mental status, and it was suggested that the mental changes were likely related to the systemic effects of sepsis and possible uremic encephalopathy, given the rising creatinine levels. The nephrology team was also brought in to assess the worsening renal function, which was now a critical concern. The increasing creatinine level and decreasing urine output suggested that the patient's kidneys were under significant stress, possibly progressing towards acute tubular necrosis if not addressed promptly.

In light of these findings, the clinical team decided to initiate renal replacement therapy via continuous venovenous hemofiltration (CVVH) to support kidney function and manage fluid overload while also considering the possibility of adjusting the antibiotic regimen to optimize therapeutic levels, especially given the resistant strain of E. coli. To improve the patient's hemodynamic status and support organ perfusion, vasopressor support was initiated with a low-dose norepinephrine infusion, as the blood pressure remained borderline low at 88/55 mmHg despite continued fluid resuscitation.

As the team implemented these interventions, they closely monitored the patient's response, specifically looking for stabilization in vital signs, improved mental status, and increased urine output. The next few hours were critical in determining the effectiveness of the new management strategies. The multidisciplinary approach was crucial, with the team remaining vigilant for any further complications, such as worsening sepsis, potential multi-organ dysfunction, or new signs of infection spread. This stage of the patient's journey highlighted the importance of dynamic clinical reasoning and the need for swift adaptation of the care plan to mitigate the developing complications effectively.

Section 5

As the clinical team monitored the patient closely following the initiation of continuous venovenous hemofiltration (CVVH) and vasopressor support, they observed a gradual stabilization of the patient's hemodynamic status. Over the next few hours, the blood pressure showed a modest improvement, rising to 95/60 mmHg, and the heart rate stabilized around 100 beats per minute. However, despite these encouraging signs, the patient's mental status remained significantly altered, with only minimal improvement noted. This prompted further evaluation of potential contributing factors, including metabolic imbalances and medication effects.

New diagnostic results revealed a slight improvement in renal function, with serum creatinine levels decreasing from 3.2 mg/dL to 2.9 mg/dL, though urine output remained low at 15 mL/hour. Blood urea nitrogen (BUN) levels also showed a marginal decrease, suggesting that the CVVH was beginning to mitigate some of the metabolic disturbances. However, a repeat complete blood count (CBC) indicated persistent leukocytosis with a white blood cell (WBC) count of 18,000/mm³, and inflammatory markers such as C-reactive protein (CRP) remained elevated, pointing to ongoing systemic inflammation.

Given the persistence of altered mental status and new lab findings, the team considered the likelihood of ongoing sepsis and began evaluating for potential sources of infection that might not have been addressed. A repeat urinalysis indicated persistent bacteriuria, and blood cultures drawn earlier returned positive for E. coli with extended-spectrum beta-lactamase (ESBL) resistance. These findings highlighted the need for an urgent review of the antibiotic regimen to ensure coverage of resistant organisms. The infectious disease specialist recommended switching to a carbapenem to better target the resistant strain. This adjustment, along with continued supportive care, was crucial to prevent further deterioration and address the underlying infection effectively.