Millie Larsen is an 84-year-old female who lives alone in a small home. She arrived with her daughter, Dina, three hours ago. Her daughter noticed that Millie wasn’t making sense or acting normally during a visit earlier today. She was seen by Dr. Lund an hour ago. He suspects urinary tract infection and has written preliminary orders. An IV has been started and labs have been drawn. They just came back. I haven’t had a chance to look at them. Her antibiotic also just arrived from the pharmacy and needs to be given. I completed a SPICES assessment, which indicated problems with incontinence and confusion. The result is in the health record. The confusion needs to be further assessed, and her fall risk should also be assessed. Can you please do that?
Patient Details
Patient Data: female- Age: 84 years. Weight: 68 kg (150 lbs). Height: 155 cm (61 in).
Allergies: No known
Past Medical History: Glaucoma, hypertension, osteoarthritis, stress incontinence, hypercholesterolemia.
History of Present Illness: Millie’s daughter became concerned when she stopped over to check on her and found her still in her bathrobe at 3 p.m. The house was very unkempt, and Millie couldn’t remember her daughter’s name.
Social History: Not recorded.
Primary Medical Diagnosis: Dehydration, suspected urinary tract infection.
Surgeries/Procedures & Dates: Cholecystectomy at age 30.
Provider’s Orders
· Bedrest, bathroom privileges with assistance
· Regular, low fat diet
· Vital signs and SpO2 every 2 hours
· I & O
· Notify physician if systolic BP > 150 or < 100; temperature > 38°C, Urine output < 60 mL in 2 hours · Ciprofloxacin 400 mg IV every 12 hours for 24 hours, then Ciprofloxacin 500 mg PO every 12 hours for 10 days. · Acetaminophen 650 mg PO every 4–6 hours as needed · IV fluids D5 0.45 NaCl + 20 mEq KCl at 60 mL/hr · CBC with diff., BMP, urine analysis, urine culture Nursing Diagnoses · Risk for Falls related to age > 65 years, diminished mental status, and antihypertensive medications
· Impaired urinary elimination related to degenerative changes in pelvic muscles and urinary tract infection
· Risk for Imbalanced Fluid Volume related to decreased oral intake of fluids, possible misuse of diuretic medications and IV fluid administration
· Acute Confusion related to fluid volume deficit and urinary tract infection
Overview of Proposed Correct Treatment
· Wash hands
· Introduce self
· Identify patient
· Obtain vital signs
· Identify elevated blood pressure
· Auscultate heart and lungs
· Assess pain
· Assess IV site, fluid and rate
· Evaluate lab data
· Identify abnormal urine analysis and electrolytes
· Begin assessments:
· Head-to-toe
· CAM assessment
· Fall risk assessment
· Focus on communication with Dina to gain necessary information for the CAM
· Educate Dina about relationship between UTI and delirium
· Identify geriatric syndromes, including confusion and incontinence
· Consider safety precautions
· Call provider and give report using SBAR
· Assess ability to take oral medications
· Administer medications
Case Considerations
Millie exhibits an atypical presentation (delirium) for a urinary tract infection that is common in the older adult population. In addition, she has other coexisting chronic conditions, including hypertension, and due to her confusion she has not been taking her medications correctly. As a result her blood pressure is highly elevated.
It is important that the nurse understands the research underlying the concept of atypical or unique presentations in older adults, how they may differ from the general adult population, and the complexity of care required by several coexisting conditions.
The focus of the assessment in this scenario is on evaluating Millie’s current condition, including assessing her confusion. Using standardized evidence-based tools for the assessments allows for a systematic approach to the patient. In this case the Confusion Assessment Method (CAM) will help to quickly and precisely identify the presence of delirium. To ensure safety, Millie’s risk of falling also needs to be assessed. Although she is living independently under normal circumstances, the acute change in her status can greatly increase her risk of falling.
The nurse should also recognize other abnormalities, including the highly elevated blood pressure and abnormal lab findings to include the urine analysis, and communicate the findings clearly and promptly to the provider. The use of the standardized SBAR format will assist with communication of clinically relevant information.
During assessments the nurse should communicate therapeutically with the daughter, Dina, as the primary source of information. It is important to focus attention on the differences between Millie’s presentation at the hospital and her normal baseline. The nurse should explain the relationship between urinary tract infection and delirium to Dina. Under normal circumstances, Millie is well-functioning, and seeing her so confused can be an upsetting experience.