Case study - Pyelonephritis: Nursing

Nurse Alfred works on a Medical-Surgical unit and is caring for Alma, a 72-year-old Spanish-speaking female with a history of multiple sclerosis, or MS, who was recently admitted for pyelonephritis. After settling Alma in her room, Nurse Alfred goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Alma's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Alfred recognizes important cues, including Alma’s vital signs, which are temperature 101.3 F, or 38.5 C, heart rate 108 beats per minute, respirations 20 breaths per minute, blood pressure 136/78 mmHg, and oxygen saturation 98 percent on room air. Nurse Alfred knows that Alma’s primary language is Spanish, so he uses an interpreter to communicate with her over the phone. Alma's lower abdomen is moderately distended, and she rates her abdominal pain at 9 out of 10.  

Nurse Alfred gathers that, at home, Alma usually empties her bladder via straight catheterization every four hours, but has been having difficulty due to increasing weakness from her MS. She reports that yesterday, she was too weak to catheterize herself.  

Next, Nurse Alfred analyzes these cues. He reviews the electronic health record, or EHR, and notes a straight catheterization was performed on Alma in the emergency department to obtain a urine sample, which revealed the presence of leukocytes and nitrites and drained 150 milliliters. Nurse Alfred realizes that, due to her inability to catheterize herself properly, Alma developed urinary retention which likely contributed to her pyelonephritis. Nurse Alfred realizes Alma needs effective urinary elimination and infection management. 

Now, using the information he's gathered, along with Alma’s medical history, Nurse Alfred chooses a priority hypothesis of infection.  

Then, he generates solutions to address Alma’s infection that will include pharmacologic and nonpharmacologic interventions, and he establishes the expected outcome that after intervening, Alma’s urinary tract infection symptoms will improve by the end of the shift.