A patient with a suspected urinary tract infection exhibits signs of systemic infection and potential renal involvement, including suprapubic tenderness, costovertebral angle tenderness, and decreased urine output. Which nursing action is the priority in managing this patient's condition?

B) Administer prescribed broad-spectrum intravenous antibiotics.

A) Increase oral fluid intake to promote diuresis.

B) Administer prescribed broad-spectrum intravenous antibiotics.

C) Apply warm compresses to the abdominal area to alleviate pain.

D) Educate the patient on the importance of completing the full course of antibiotics.

A 45-year-old female patient presents with worsening abdominal pain, dysuria, turbid urine, and costovertebral angle tenderness. Her laboratory results show leukocytosis and elevated serum creatinine. Despite starting broad-spectrum IV antibiotics, her temperature remains elevated and she is tachycardic. Which of the following nursing interventions is most critical to implement at this time to address her condition?

B) Monitor urine output hourly to assess renal function.

A) Encourage oral fluid intake to promote diuresis.

B) Monitor urine output hourly to assess renal function.

C) Administer antipyretics to manage fever.

D) Prepare the patient for immediate imaging studies.

A patient with suspected pyelonephritis is receiving broad-spectrum intravenous antibiotics but shows signs of deteriorating renal function and oliguria. Which nursing intervention is most critical to prevent further renal compromise and address the patient's hemodynamic instability?

B) Administer prescribed vasopressors to maintain adequate blood pressure.

A) Increase the rate of intravenous fluids to enhance renal perfusion.

B) Administer prescribed vasopressors to maintain adequate blood pressure.

C) Encourage oral hydration to improve urine output.

D) Wait for urine culture results to adjust antibiotic therapy.

A patient with suspected pyelonephritis is exhibiting signs of acute kidney injury and possible septic shock. The healthcare team has initiated broad-spectrum antibiotics, fluid resuscitation, and vasopressor support. What is the priority nursing intervention to prevent further renal compromise?

B) Monitor urine output hourly and report any decrease immediately.

A) Increase the rate of intravenous fluids to enhance renal perfusion.

B) Monitor urine output hourly and report any decrease immediately.

C) Administer acetaminophen to manage the patient's fever effectively.

D) Prepare the patient for immediate hemodialysis to support renal function.

A patient with a resistant Escherichia coli infection and increasing serum lactate levels is showing signs of fluctuating mental status and acute kidney injury. What is the nurse's priority intervention to address the patient's current clinical status?

A) Administer the prescribed carbapenem antibiotic immediately to address the resistant infection.

B) Initiate continuous renal replacement therapy (CRRT) to manage acute kidney injury and remove nephrotoxins.

C) Monitor neurological status closely and prepare for potential transfer to the intensive care unit for increased observation.

D) Collaborate with the healthcare team to adjust the vasopressor support to maintain adequate blood pressure.

A patient with a resistant strain of Escherichia coli is experiencing clinical instability with increasing serum lactate levels and fluctuating mental status. The healthcare team is considering continuous renal replacement therapy (CRRT). What is the primary nursing consideration when initiating CRRT in this patient?

C) Adjusting the fluid removal rate based on the patient's hemodynamic status.

A) Ensuring the patient's nutritional needs are met during CRRT.

B) Monitoring for signs of infection at the vascular access site.

C) Adjusting the fluid removal rate based on the patient's hemodynamic status.

D) Evaluating the patient's electrolyte levels once daily.

A patient with septic shock is not responding adequately to the current antibiotic therapy and vasopressor support. The healthcare team decides to initiate continuous renal replacement therapy (CRRT). What is the primary nursing consideration when preparing the patient for CRRT?

B) Monitor the patient's electrolyte levels closely during CRRT.

A) Administer a diuretic to increase urine output before starting CRRT.

B) Monitor the patient's electrolyte levels closely during CRRT.

C) Decrease fluid intake to prevent fluid overload during CRRT.

D) Ensure a high-protein diet to support renal function during CRRT.

A patient with suspected septic shock is now receiving continuous renal replacement therapy (CRRT) due to worsening acute kidney injury. Which nursing intervention is most crucial to prioritize for this patient?

B) Maintain strict aseptic technique when accessing the CRRT system.

A) Monitor urine output every hour to assess renal function.

B) Maintain strict aseptic technique when accessing the CRRT system.

C) Assess lung sounds every 4 hours to detect fluid overload.

D) Encourage early mobilization to prevent deep vein thrombosis.

A patient undergoing continuous renal replacement therapy (CRRT) for acute kidney injury is also being treated for septic shock and a polymicrobial infection. The patient's urine output has increased slightly, but her blood pressure remains low despite vasopressor therapy. Which nursing intervention is most appropriate to address the patient's persistent hypotension and support improved tissue perfusion?

B) Collaborate with the healthcare team to reassess and adjust vasopressor dosages.

A) Increase the rate of intravenous crystalloid fluid infusion.

B) Collaborate with the healthcare team to reassess and adjust vasopressor dosages.

C) Position the patient in Trendelenburg to increase venous return and cardiac output.

D) Administer a diuretic to reduce fluid overload and improve cardiac function.

A patient receiving continuous renal replacement therapy (CRRT) for sepsis with multiple organ dysfunctions is experiencing persistent hypotension, increased respiratory effort, and neurological decline. Which nursing intervention should be prioritized to address the patient's current condition?

C) Collaborate with the healthcare team to adjust the vasopressor therapy and address the potential source of infection.

A) Increase the rate of CRRT to enhance fluid removal and improve blood pressure.

B) Administer a bolus of normal saline to temporarily increase blood pressure.

C) Collaborate with the healthcare team to adjust the vasopressor therapy and address the potential source of infection.

D) Prepare the patient for immediate intubation and mechanical ventilation to improve respiratory status.

CAUTI - Nursing Case Study

Pathophysiology

• Primary mechanism: Bacterial colonization occurs when microorganisms, commonly E. coli, ascend through the catheter lumen or along the urethral mucosa, bypassing normal host defenses.

• Secondary mechanism: Biofilm formation on the catheter surface protects bacteria from the host immune response and antibiotics, facilitating persistent infection.

• Key complication: Persistent infection can lead to local inflammation, causing urethritis or cystitis, and may progress to more severe infections such as pyelonephritis or sepsis if not managed promptly.

Patient Profile

Demographics:

58-year-old female, retired school teacher

History:

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

• Current medications: Metformin 500 mg BID, Lisinopril 10 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing lower abdominal pain and fever

• Key symptoms: Dysuria, cloudy and foul-smelling urine, chills, lethargy, nausea

• Vital signs: Temperature 101.8°F, heart rate 112 bpm, blood pressure 138/88 mmHg, respiratory rate 22 breaths per minute, SpO2 95% on room air

Section 1

As the healthcare team conducts an initial assessment, the patient exhibits signs of worsening infection. Her lower abdominal pain has intensified, and she is visibly uncomfortable, frequently shifting in her bed. Physical examination reveals suprapubic tenderness upon palpation, and the presence of costovertebral angle tenderness suggests possible renal involvement. The patient reports increased dysuria and notes that the volume of her urine has decreased over the past 24 hours. Her urine sample appears turbid, reinforcing suspicions of a urinary tract infection.

Laboratory results further illuminate the situation: her complete blood count shows leukocytosis with a white blood cell count of 15,000/mm³, indicating a systemic inflammatory response. A urinalysis confirms significant pyuria and bacteriuria, while urine culture is pending. Blood cultures have also been drawn to assess for potential bacteremia, given her febrile state and tachycardia. Renal function tests reveal a slight elevation in serum creatinine to 1.4 mg/dL, hinting at the possibility of acute kidney involvement, possibly due to ascending infection.

The patient's clinical status prompts immediate intervention. She is started on broad-spectrum intravenous antibiotics, tailored to cover common uropathogens, pending culture results. Additionally, her catheter is removed and replaced under sterile conditions to minimize further contamination and biofilm formation. Despite these measures, her temperature remains elevated, and her heart rate continues to be tachycardic, suggesting that the infection may be progressing. The healthcare team must closely monitor her for signs of sepsis and renal compromise, preparing to escalate care if necessary. This situation presents an opportunity for the team to refine their clinical reasoning, as they consider the potential need for imaging studies to assess for complications like pyelonephritis or abscess formation.

Section 2

As the healthcare team continues to monitor the patient, her condition evolves with new complications. Despite the initiation of broad-spectrum intravenous antibiotics, the patient exhibits signs of deteriorating renal function. Her serum creatinine level has increased to 1.8 mg/dL within 24 hours, and her blood urea nitrogen has also risen to 28 mg/dL, indicating a potential acute kidney injury secondary to the suspected pyelonephritis. The patient's urine output has further decreased to less than 400 mL in the past 24 hours, suggesting oliguria. These developments prompt the healthcare team to consider more aggressive interventions to prevent further renal compromise.

The patient's vital signs remain concerning, with a persistent fever of 102.5°F (39.2°C) and a heart rate of 112 beats per minute. Despite fluid resuscitation, her blood pressure has dropped to 95/60 mmHg, raising concerns about possible septic shock. The team decides to start the patient on vasopressor support to maintain adequate perfusion. Additionally, given the potential renal involvement, the decision is made to order a renal ultrasound to assess for possible obstructive uropathy or abscess formation, which could explain the patient's worsening condition.

The pending urine culture results are anticipated to guide more targeted antibiotic therapy, but the immediate priority is stabilizing the patient's hemodynamic status while preventing further kidney injury. The healthcare team remains vigilant for changes in the patient's mental status or respiratory function, as these could signal worsening sepsis. This scenario underscores the importance of dynamic clinical reasoning as the team evaluates the effectiveness of interventions, adjusts the treatment plan, and prepares for potential escalation of care based on the evolving clinical picture.

Section 3

As the healthcare team continues to manage the patient's condition, new diagnostic results provide further insight into her deteriorating status. The renal ultrasound reveals no evidence of obstructive uropathy but does show mild hydronephrosis, which could be secondary to the ongoing infection and inflammation. In the meantime, the results from the urine culture come back, identifying a resistant strain of Escherichia coli as the causative organism. This finding necessitates a shift in antibiotic therapy to a more targeted approach, utilizing a carbapenem known to effectively combat this resistant strain.

Despite these adjustments, the patient's clinical status remains unstable. Her serum lactate levels have increased to 3.5 mmol/L, a concerning indicator of ongoing tissue hypoperfusion and possible progression towards septic shock. The vasopressor support has helped stabilize her blood pressure temporarily, but the team notes that her mental status is fluctuating, with periods of confusion and lethargy. This change raises alarms about potential central nervous system involvement, possibly due to sepsis-associated encephalopathy.

In response to these developments, the healthcare team intensifies their monitoring efforts and considers the need for continuous renal replacement therapy (CRRT) to manage the acute kidney injury and remove potential nephrotoxic substances from her system. The emphasis is on a multidisciplinary approach to optimize the patient's care, involving nephrology, infectious disease specialists, and critical care expertise. As the situation evolves, the team remains prepared to escalate the level of care, understanding that timely interventions are crucial for preventing further complications and improving the patient's chances of recovery.

Section 4

With the shift in antibiotic therapy to a carbapenem, the healthcare team closely monitors the patient for any signs of improvement. However, over the next 24 hours, the patient's condition takes a concerning turn. Her vital signs reveal a fever of 39.2°C, tachycardia with a heart rate of 115 beats per minute, and hypotension with blood pressure readings consistently around 88/56 mmHg despite vasopressor support. The urine output remains critically low at 15 mL/hour, and her respiratory rate has increased to 28 breaths per minute, indicating increased respiratory effort.

New laboratory results show a further elevation in serum creatinine to 3.0 mg/dL, confirming worsening acute kidney injury. Additionally, her white blood cell count has risen to 18,000/mm³, suggesting an ongoing infectious process. The fluctuating mental status persists, with the patient now presenting with disorientation and difficulty following simple commands, reinforcing concerns about sepsis-associated encephalopathy. These findings suggest that the infection may not be fully controlled, and there is a high risk of progression to septic shock.

Given these developments and the potential for rapid deterioration, the medical team decides to initiate continuous renal replacement therapy (CRRT) to support renal function and aid in the clearance of inflammatory mediators. The infectious disease team reevaluates the antimicrobial regimen, considering the possibility of a polymicrobial infection or additional sources of infection. The critical care team prioritizes maintaining hemodynamic stability and optimizing oxygen delivery. As the patient remains in a delicate balance, the team's collaborative efforts focus on mitigating further complications and improving her overall prognosis through timely and precise interventions.

Section 5

As the continuous renal replacement therapy (CRRT) is initiated, the healthcare team closely monitors the patient's response to this critical intervention. Over the next several hours, the patient's urine output shows a slight improvement, increasing to 25 mL/hour, which is a positive sign of renal recovery. However, her overall condition remains precarious. Her blood pressure remains low, fluctuating between 85/50 mmHg and 90/54 mmHg, despite adjustments in vasopressor doses. The persistent hypotension raises concerns about ongoing septic shock and inadequate tissue perfusion.

New diagnostic results reveal that blood cultures have grown two different organisms: Escherichia coli, which was previously identified, and now Enterococcus faecium, suggesting a polymicrobial infection. This finding prompts the infectious disease team to broaden the antimicrobial regimen to include linezolid to target the resistant Enterococcus species. Additionally, a chest X-ray performed due to the patient's increased respiratory rate and effort shows bilateral infiltrates, raising suspicion for possible pneumonia as an additional source of infection.

The critical care team continues to assess the patient's neurological status, which remains concerning. She now exhibits increased agitation and asterixis, indicative of worsening encephalopathy. This neurological decline, coupled with the new findings of pulmonary involvement, necessitates a reevaluation of the treatment strategy. The team considers the need for further diagnostic imaging and possibly bronchoscopy to clarify the lung pathology. As the patient's situation evolves, the healthcare team remains vigilant, adapting their approach to address the multifaceted challenges in managing this complex case of sepsis with multiple organ dysfunctions.