urinary tract infection with high fever - Nursing Case Study

Pathophysiology

• Primary mechanism: UTIs typically occur when bacteria, primarily Escherichia coli, enter the urinary tract through the urethra and proliferate in the bladder. In some cases, the infection can spread to the kidneys causing pyelonephritis.

• Secondary mechanism: The body's immune response to the bacterial invasion leads to inflammation and irritation of the urinary tract, causing symptoms such as dysuria. If the infection reaches the kidneys, it triggers a systemic immune response, resulting in a high fever.

• Key complication: If not treated promptly, the infection can cause kidney damage. Additionally, recurrent UTIs can lead to complications such as kidney stones, urinary incontinence, and sepsis, a potentially life-threatening condition.

Patient Profile

Demographics:

45-year-old female, office worker

History:

• Key past medical history: Recurrent urinary tract infections, Type 2 diabetes

• Current medications: Metformin for diabetes

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe lower abdominal pain, high fever

• Key symptoms: Burning sensation during urination, frequent urination, cloudy and foul-smelling urine, high fever of 103°F, nausea, and vomiting

• Vital signs: Blood pressure 130/85 mm Hg, pulse 110 beats per minute, respiratory rate 20 breaths per minute, temperature 103°F

Section 1

New Diagnostic Results:

The patient's lab results show a white blood cell count of 18,000 cells/mm3, indicative of an infection. Urinalysis shows the presence of nitrites, leukocyte esterase, and a high count of bacteria, specifically E.coli. This suggests a urinary tract infection. The patient's blood glucose level is elevated at 180 mg/dL, indicating poor control of her diabetes, which is likely contributing to the severity of her infection. A CT scan reveals inflammation in the right kidney, suggesting that the infection has spread and is now a case of pyelonephritis.

The elevated white blood cell count, presence of nitrites and leukocyte esterase in the urine, and the identification of E.coli bacteria confirm the initial suspicion of a UTI. The inflammation in the kidney seen in the CT scan, along with the patient's high fever, suggests that she has developed pyelonephritis, a serious complication of UTI. The poorly controlled diabetes is likely impairing her immune response, making it harder for her body to fight off the infection. This case requires careful management to treat the infection, prevent further kidney damage, and manage her diabetes.

Section 2

Change in Patient Status:

Over the next 24 hours, the patient's condition seems to deteriorate. Her fever spikes to 102.7°F, and she reports increased flank pain. Additionally, she complains of increased frequency and urgency of urination, along with dysuria. Her blood pressure drops to 90/60 mmHg, and her pulse rate increases to 110 beats/minute. These signs suggest that the infection is spreading and that her body is struggling to fight it off.

Despite the ongoing antibiotic therapy, it appears that the patient is not responding as expected. This could be due to a number of factors, including the possibility that the bacteria causing the infection are resistant to the antibiotic being used, or that her poorly controlled diabetes is further impairing her immune response. Her low blood pressure and increased heart rate could also indicate the onset of sepsis, a potentially life-threatening complication. Immediate re-evaluation of her treatment plan is warranted to prevent further deterioration of her health.

Section 3

New Diagnostic Results:

Upon re-evaluating the patient's condition, the medical team decides to conduct further diagnostic tests. A repeat urinalysis is performed, which shows a significant increase in the number of white blood cells, indicating a worsening infection. A urine culture is also ordered to identify the specific bacteria causing the infection, and the results come back positive for Escherichia coli (E. coli), which is known to be resistant to many types of antibiotics.

A blood culture is also ordered to check for the presence of bacteria in the bloodstream, a sign of sepsis. The results show an elevated number of bacteria, confirming the suspicion of sepsis. Her blood glucose levels remain high at 250 mg/dL, reflecting the poorly controlled diabetes. Furthermore, her kidney function tests show elevated levels - creatinine at 1.8 mg/dL and blood urea nitrogen (BUN) at 25 mg/dL, indicating potential kidney damage or dysfunction due to the severe infection.

These new diagnostic results provide vital information on why the patient's condition is not improving as expected. It suggests that the current antibiotic treatment is not effective against the identified bacteria, and her diabetes is worsening her body's ability to fight off the infection. These findings require immediate changes to her treatment plan, including the selection of a more effective antibiotic and better management of her diabetes. The elevated kidney function tests also raise concern for potential kidney damage, which will need to be monitored closely.

Section 4

New Complications:

Over the coming hours, the patient's condition deteriorates. She becomes increasingly lethargic and disoriented, unable to answer questions or follow simple commands. Her vital signs are unstable - her blood pressure drops to 90/60 mmHg, and her heart rate increases to 120 beats per minute. These findings suggest the possibility of septic shock, a severe and potentially life-threatening complication of sepsis.

In addition to mental changes and unstable vital signs, her kidney function continues to worsen. A repeat test shows her creatinine levels have increased to 2.4 mg/dL, and her BUN level is 30 mg/dL. These elevated levels indicate that her kidneys are not effectively filtering waste products from her blood, a condition known as acute kidney injury (AKI). The AKI, combined with her ongoing urinary tract infection, uncontrolled diabetes, and potential septic shock, present a complex and critical situation requiring swift and decisive medical intervention. The medical team needs to review and adjust her treatment plan quickly to prevent further deterioration of her condition and potential multi-organ failure.

Section 5

Change in Patient Status:

Despite the team's best efforts, the patient's condition continues to worsen. She becomes non-responsive and her heart rate increases to 135 beats per minute. Her blood pressure drops further to 85/50 mmHg, indicating a concerning progression of the suspected septic shock. The patient's respiratory rate also increases to 28 breaths per minute, suggesting she is experiencing difficulty in maintaining adequate oxygenation.

Her skin is now cool and clammy to the touch, with a mottled appearance on her extremities. This is a sign of poor peripheral perfusion, caused by the body's attempt to divert blood flow to vital organs. This clinical change could indicate an increased risk of tissue hypoxia and eventual organ dysfunction if not immediately addressed. The medical team needs to act quickly to stabilize the patient's deteriorating vital signs and prevent further complications. The focus now shifts to aggressive fluid resuscitation, vasopressor therapy, and the administration of broad-spectrum antibiotics while awaiting the results of the blood cultures. The situation remains critical, with the need for ongoing close monitoring and swift decision-making based on the patient's responses to these interventions.