A 28-year-old female patient with a known penicillin allergy presents with signs of pyelonephritis. Her urinalysis shows significant pyuria and her urine culture reveals Escherichia coli. Given her allergy and clinical presentation, which antibiotic would be the most appropriate initial choice for her treatment?

D) Trimethoprim-sulfamethoxazole

A patient with a confirmed Escherichia coli urinary tract infection and a penicillin allergy presents with symptoms indicative of pyelonephritis. Given her current condition and allergy, which of the following is the most appropriate nursing intervention to prioritize?

C) Start intravenous cephalosporin therapy and closely monitor vitals and renal function.

A) Administer oral penicillin to manage the infection.

B) Initiate oral nitrofurantoin therapy and monitor for adverse reactions.

C) Start intravenous cephalosporin therapy and closely monitor vitals and renal function.

D) Encourage increased fluid intake and reassess in 48 hours.

A patient with suspected sepsis is experiencing a drop in blood pressure, elevated heart rate, and a fever of 103.8°F. Laboratory results indicate thrombocytopenia, elevated lactate, and creatinine levels. Which nursing intervention is the highest priority to address the patient's hemodynamic instability?

B) Initiate aggressive fluid resuscitation

A) Administer antipyretics to reduce fever

B) Initiate aggressive fluid resuscitation

C) Administer vasopressors to increase blood pressure

D) Prepare for nephrology consultation

A patient with confirmed E. coli bacteremia is transferred to a higher level of care due to suspected septic shock. Her current vital signs include a fever of 103.8°F, blood pressure of 95/60 mmHg, heart rate of 120 bpm, and laboratory findings show a platelet count of 90,000/mm³, elevated lactate level, and increased creatinine. What is the nurse's priority intervention to address her hemodynamic instability?

B) Initiate aggressive fluid resuscitation

A) Administer broad-spectrum antibiotics

B) Initiate aggressive fluid resuscitation

C) Prepare for central line insertion

A patient in the ICU is receiving treatment for septic shock, including fluid resuscitation and vasopressor support. Despite these interventions, the patient's lactate levels remain elevated, and urine output has decreased. Which of the following nursing actions is most appropriate to address the patient's current condition?

B) Monitor the patient closely for signs of fluid overload and adjust fluid therapy as necessary.

A) Increase the rate of isotonic fluid infusion to improve tissue perfusion.

B) Monitor the patient closely for signs of fluid overload and adjust fluid therapy as necessary.

C) Request an increase in the norepinephrine dosage to further support blood pressure.

D) Initiate renal replacement therapy as per nephrology's suggestion to manage acute kidney injury.

A patient in the ICU is receiving aggressive fluid resuscitation and vasopressor support due to septic shock. Which nursing intervention is most critical in monitoring the effectiveness of these treatments?

B) Monitor the patient's urine output hourly to evaluate renal perfusion.

A) Measure the patient's daily weight to assess for fluid overload.

B) Monitor the patient's urine output hourly to evaluate renal perfusion.

C) Check the patient's blood glucose levels every 4 hours to detect hyperglycemia.

D) Assess the patient's skin for signs of pallor or cyanosis every shift.

A patient in the ICU exhibits fluctuating mental status, respiratory distress, and decreased urine output after being diagnosed with septic shock. The healthcare team has initiated non-invasive positive pressure ventilation (NIPPV) and is considering mechanical ventilation. Which nursing action is most important to prioritize at this time?

B) Prepare for possible intubation and mechanical ventilation.

A) Increase fluid intake to improve urine output.

B) Prepare for possible intubation and mechanical ventilation.

C) Administer a sedative to help the patient rest.

D) Begin dialysis to manage the patient's renal status.

A patient in the ICU is showing signs of respiratory distress, confusion, and lethargy, with an arterial blood gas analysis indicating respiratory acidosis. Despite supplemental oxygen, the patient's condition is worsening. Which nursing intervention should be prioritized to stabilize the patient's respiratory status?

B) Initiate non-invasive positive pressure ventilation (NIPPV)

A) Increase the flow rate of supplemental oxygen via nasal cannula

B) Initiate non-invasive positive pressure ventilation (NIPPV)

C) Administer a sedative to reduce agitation and conserve energy

D) Prepare for immediate intubation and mechanical ventilation

A patient in the ICU is diagnosed with developing acute respiratory distress syndrome (ARDS) and acute kidney injury secondary to sepsis. The medical team is considering adjusting her antibiotic regimen and initiating renal replacement therapy. What is the most critical nursing intervention to prioritize at this time?

B) Prepare the patient for potential intubation to address respiratory distress.

A) Monitor the patient's urine output hourly to assess kidney function.

B) Prepare the patient for potential intubation to address respiratory distress.

C) Administer scheduled antibiotics and assess their effectiveness.

D) Educate the patient and family about the progression of her condition and treatment options.

A patient in the ICU is diagnosed with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) secondary to sepsis. The patient's urine output is decreasing, and the nephrology team is considering renal replacement therapy. Which nursing intervention is most important to implement at this time?

A) Monitor and document the patient's daily weight and fluid intake/output.

B) Place the patient in a high Fowler's position to improve respiratory function.

C) Administer diuretics as prescribed to increase urine output.

D) Encourage oral fluid intake to prevent dehydration.

urinary tract infection - Nursing Case Study

Pathophysiology

• Primary mechanism: Bacterial colonization - Uropathogens, primarily Escherichia coli, migrate from the perineum into the urethra, ascending into the bladder. They adhere to the urothelial cells using pili and fimbriae, evading the host's immune response.

• Secondary mechanism: Inflammatory response - The presence of bacteria triggers an immune reaction, releasing cytokines and chemokines. This leads to inflammation of the urinary tract lining, causing symptoms such as dysuria, urgency, and frequency.

• Key complication: Pyelonephritis - If untreated, bacteria can ascend to the kidneys, causing severe inflammation and potential renal scarring, which can lead to systemic infection and impaired kidney function.

Patient Profile

Demographics:

35-year-old female, office manager

History:

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

• Current medications: Lisinopril 10 mg daily, cranberry supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Worsening lower abdominal pain and frequent urination

• Key symptoms: Dysuria, hematuria, fever, chills, and fatigue

• Vital signs: Temperature 101.3°F, heart rate 105 bpm, blood pressure 150/95 mmHg, respiratory rate 20 breaths per minute, oxygen saturation 98% on room air

Section 1

Change in Patient Status:

Two days following the initial presentation, the patient returns to the clinic with worsening symptoms. She reports increased severity of lower back pain, particularly on the right side, and a noticeable increase in frequency and urgency of urination. Her fever has persisted, now peaking at 102.5°F. On physical examination, there is noticeable costovertebral angle tenderness on the right side, indicating possible progression to pyelonephritis. Her vital signs show a heart rate of 110 bpm and blood pressure of 155/98 mmHg, suggesting her body is under stress, potentially from the escalation of the infection.

A urinalysis reveals significant pyuria, with a high white blood cell count, and moderate hematuria. The urine culture confirms the presence of Escherichia coli, with a high colony count suggestive of an upper urinary tract infection. Blood tests indicate leukocytosis with a left shift, supporting the diagnosis of a systemic inflammatory response. Given her penicillin allergy, the healthcare team considers alternative antibiotics, such as nitrofurantoin or a cephalosporin, to address the infection effectively while minimizing the risk of adverse reactions.

The clinical reasoning at this stage focuses on the importance of early intervention to prevent further complications, such as renal scarring or sepsis. The team decides to initiate intravenous antibiotic therapy due to the severity of the symptoms and the potential for rapid progression. The patient's response to this intervention will be critical in determining the next steps, including the potential need for hospitalization if her condition does not improve promptly. Close monitoring of her vital signs, renal function, and symptom progression will guide further clinical decisions.

Section 2

New Complications

Despite the initiation of intravenous antibiotic therapy, the patient experiences a concerning change in her condition over the next 24 hours. Her fever escalates to 103.8°F, and she develops chills and rigors, suggesting a potential progression towards sepsis. Her blood pressure drops to 95/60 mmHg, indicating possible septic shock, and her heart rate remains elevated at 120 bpm. This hemodynamic instability, combined with her persistent symptoms, prompts immediate reassessment by the healthcare team.

Laboratory results reveal a significant drop in her platelet count, now at 90,000/mm³, and an elevated lactate level of 3.5 mmol/L. Her creatinine level has risen to 2.1 mg/dL, suggesting acute kidney injury, likely secondary to the infection and compromised perfusion. Blood cultures are drawn and later confirm bacteremia with E. coli, underscoring the systemic spread of the infection. Given these findings, the clinical team recognizes the urgent need to escalate care. They decide to transfer the patient to a higher level of care for closer monitoring and potential intensive care support.

Clinically, this situation necessitates a comprehensive reassessment of the treatment plan, including the possibility of broadening the antibiotic coverage and ensuring aggressive fluid resuscitation to stabilize her hemodynamics. The team must also consider the patient's renal function and potential need for nephrology consultation. The focus shifts to preventing further deterioration, managing septic shock, and addressing the complications effectively. The patient's response to these interventions will be closely monitored to guide further therapeutic decisions and ensure optimal recovery.

Section 3

The patient is transferred to the intensive care unit (ICU) for closer monitoring and aggressive management of her impending septic shock. Upon arrival, the ICU team conducts a thorough initial assessment. Her vital signs reveal a critical state: blood pressure remains hypotensive at 88/58 mmHg, heart rate is persistently elevated at 130 bpm, and her respiratory rate has increased to 28 breaths per minute, with oxygen saturation dropping to 90% on room air. She appears diaphoretic and slightly confused, with a decreased level of consciousness indicating possible cerebral hypoperfusion.

In response, the ICU team initiates an aggressive fluid resuscitation protocol with isotonic crystalloids to improve her hemodynamic status. Given her acute kidney injury and elevated creatinine, they carefully monitor her fluid balance to avoid fluid overload. Meanwhile, the decision is made to broaden antibiotic coverage to include vancomycin and piperacillin-tazobactam, targeting both gram-negative and gram-positive bacteria, while awaiting further sensitivity results from the blood cultures. Vasopressor support with norepinephrine is started to maintain her mean arterial pressure above 65 mmHg, essential for ensuring adequate organ perfusion.

Despite these interventions, over the next several hours, the patient exhibits minimal improvement. Her lactate levels remain high, now at 4.2 mmol/L, indicating persistent tissue hypoperfusion. Her urine output decreases significantly, raising concerns about worsening renal function. The nephrology team is consulted, and they discuss the potential need for renal replacement therapy should her condition not improve. The multidisciplinary team remains vigilant, adjusting treatment strategies as needed and preparing for potential escalations in care, with the aim of stabilizing the patient and preventing further complications.

Section 4

The ICU team continues to closely monitor the patient's condition, noting that her mental status fluctuates between confusion and lethargy, which prompts a repeat neurological assessment. As the hours progress, a new complication emerges: the patient begins to exhibit signs of respiratory distress, with increased work of breathing and use of accessory muscles. Her oxygen saturation drops further to 85% despite supplemental oxygen via nasal cannula. An arterial blood gas analysis is performed, revealing a respiratory acidosis with pH at 7.28, PaCO2 elevated at 52 mmHg, and PaO2 reduced to 58 mmHg. These findings suggest worsening respiratory function, likely secondary to evolving acute respiratory distress syndrome (ARDS), a known complication of septic shock.

In response to the deteriorating respiratory status, the ICU team decides to escalate to non-invasive positive pressure ventilation (NIPPV) to improve oxygenation and reduce the work of breathing. They carefully titrate the settings to optimize gas exchange while monitoring for signs of fatigue or further decline. Despite these efforts, her clinical picture remains concerning, prompting an urgent discussion about the need for intubation and mechanical ventilation should her condition fail to stabilize. Concurrently, her decreasing urine output and rising creatinine levels necessitate further consideration of renal replacement therapy, as the nephrology team re-evaluates her kidney function and fluid status.

As the team assesses the broader picture, they emphasize the critical need for a coordinated approach, involving frequent reassessment and adjustment of treatment strategies. They re-evaluate potential sources of infection and consider additional imaging to rule out any obstructive causes that might have contributed to the initial urinary tract infection. The immediate goal remains to stabilize the patient’s vital signs and organ function, preventing further deterioration while planning for long-term recovery strategies.

Section 5

As the ICU team continues to monitor the patient, a new set of diagnostic results returns, providing further insight into her condition. A recent chest X-ray reveals bilateral infiltrates, consistent with developing acute respiratory distress syndrome (ARDS). This finding corroborates the earlier arterial blood gas results, aligning with the clinical picture of worsening respiratory function. Additionally, a repeat complete blood count shows a white blood cell count of 18,000/mm³, indicating a persistent inflammatory response likely driven by ongoing infection. Blood cultures taken earlier still show growth of E. coli, suggesting that the urinary tract infection has advanced to a more systemic involvement.

The team also receives results from a renal ultrasound, which shows no evidence of obstruction or hydronephrosis, ruling out obstructive causes for the urinary tract infection but highlighting the kidneys' vulnerability to septic shock. Her serum creatinine has increased to 2.4 mg/dL, further supporting acute kidney injury secondary to sepsis. As her urine output continues to dwindle, the nephrology team contemplates initiating renal replacement therapy to manage her fluid balance and remove toxins from her bloodstream more effectively.

With these new diagnostic insights, the multidisciplinary team emphasizes the need for heightened vigilance and rapid adaptation of the treatment plan. They consider adjusting her antibiotic regimen to ensure it is optimally targeting the identified pathogen, while also preparing for the potential need for intubation if her respiratory status does not improve. This holistic approach underscores the complexity of managing a critically ill patient with multiple organ dysfunction, demanding precise clinical reasoning and prompt decision-making to navigate the unfolding challenges and steer the patient towards stabilization and recovery.