Video Case Study - Caring for Patients With Urinary Tract Infection

Nurse Steven is working in a long-term care facility and is caring for Louisa, a 79-year-old female with a history of diabetes mellitus.

In collaboration with the registered nurse, RN Gene, Nurse Steven goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Louisa’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Steven recognizes important cues, including Louisa’s vital signs, which are temperature 99.0 F or 37.2 C, heart rate 86 beats per minute, respirations 16 breaths per minute, and blood pressure 108/52 mmHg.

He also notices Louisa has asked to use the bedside commode to urinate four times in the past hour. Louisa also reports burning with urination and suprapubic discomfort that she rates as 6 out of 10 on the pain scale.

Next, Nurse Steven analyzes these cues. He reviews the electronic health record, or EHR, and notes that Louisa's biological sex, age, and medical history can increase the risk for developing urinary tract infections, or UTIs.

He knows that patients assigned female at birth have shorter urethras, making it easier for bacteria to travel to the bladder; and that decreased estrogen following menopause results in atrophy of the urinary tract which can lead to decreased bladder emptying, urinary stasis, and more time for bacteria to grow in the urinary tract.

Urinary stasis can also occur in some patients with diabetes mellitus, where impaired smooth muscle contractility of the urinary tract leads to urinary retention.

Nurse Steven also knows that as bacteria multiply within the urinary tract, they cause inflammation, which leads to suprapubic pain, feelings of bladder fullness, as well as urinary frequency and urgency.

Nurse Steven realizes Louisa needs effective urinary elimination. Now, using the information he has gathered, along with Louisa’s medical history, Nurse Steven reports his findings to RN Gene, who chooses a priority hypothesis of altered urinary elimination.

They perform a dipstick urinalysis of a clean-catch specimen, per facility protocol, which reveals the presence of nitrites, white blood cells, and leukocyte esterase, which indicate bacteriuria and pyuria.

Nurse Steven then calls the health care provider to report their findings, who orders a urine culture, and PO sulfamethoxazole-trimethoprim for Louisa.

Then, Nurse Steven collaborates with RN Gene to generate solutions to address Louisa’s altered urinary elimination that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Louisa will report decreased urinary frequency and suprapubic pain within 48 hours.

Nurse Steven then takes action to implement these solutions. He collects the urine culture and sends it to the lab, as ordered.

RN Gene teaches Louisa about her UTI and the prescribed antibiotic. Nurse Steven then enters Louisa’s room with the medication.

Nurse Steven: Hi, Louisa. I have a medication called sulfamethoxazole-trimethoprim to treat your UTI.

Louisa: I’ve had UTIs before. It seems like I get one every few months.

Nurse Gene mentioned a few things that could help me from getting UTIs in the future, but I forgot to write them down. Could you go over them with me again?

Nurse Steven: Sure, there are few things you can do to prevent UTIs, like increasing your fluid intake and by emptying your bladder as soon as you feel the urge to go.

Also, be sure to wipe from front to back after using the bathroom. For now, you should avoid caffeinated beverages, like coffee and carbonated beverages, like sodas, since they can irritate your bladder.

Louisa: That makes sense, but I’d rather not drink a lot of water because then I’ll have to go to the bathroom more often and it hurts when I go.

Nurse Steven: I understand that it's uncomfortable. But keep in mind, water is necessary to flush the bacteria from your urinary system and, along with the medication, it will help resolve your symptoms.

I also have a warm compress for your abdomen. Would you like to try that?

Louisa: Yes, that sounds great. Nurse Steven then administers the medication according to the principles of safe medication administration.

He assists Louisa to get comfortable in bed, applies the warm compress, and places the call light where she can easily reach it.

Two days later, Nurse Steven evaluates the outcome of his actions. He takes Louisa’s vital signs which are temperature 98.6 F, or 37 C, heart rate 84 beats per minute, respirations 16 breaths per minute, and blood pressure 112/64 mmHg.

Louisa tells Nurse Steven that her urinary frequency has improved, and she no longer has any abdominal pain. Alright, as a quick recap…Nurse Steven recognized and analyzed cues related to Louisa’s urinary tract infection and in collaboration with RN Gene, prioritized hypotheses, and generated solutions to address this