Components of Critical Thinking
Assumptions
The patient has sudden deterioration, hyperthermia, chills, tachycardia, oliguria and symptoms of general intoxication, aggravating the main uropathology. There are signs of uncontrolled release of endogenous mediators with the subsequent development of inflammation, organ system damage, or pyemic foci that are separated from the primary focus of infectious inflammation. Most likely, this is a generalized nonspecific infectious and inflammatory process caused by the penetration of uroinfectious pathogens and their toxins into the bloodstream.
Data Inconsistencies
A person with a generalized nonspecific infectious and inflammatory process is often accompanied by vomiting, but this patient does not have this symptom.
Data Clusters
- Neurological System. The patient does not react to external signals; meningeal signs are negative, and cranial nerves are without focal pathology. The patient opens her eyes with loud handling or braking, and pain stimulation. Surface and deep sensitivity is preserved. However, the patient cannot swallow and is not conscious.
- Respiratory System. Breath sounds equal with crackle throughout. This occurs when it is difficult to pass air through the bronchi due to their swelling, filling with sputum, dust, irritating substances or a foreign body entering the lungs through the nasal cavity.
- Cardiac System. The patient has sinus arrhythmia and irregular sinus rhythm. This arrhythmia is caused by fluctuations in the automatic activity of the sinus-atrial node. Most likely, it is associated with changes in parasympathetic regulation, and physiological fluctuations in the frequency of the sinus rhythm are associated with breathing.
- Gastrointestinal System. The abdomen of the patient is soft, flat and non-tender, with diminished bowel sounds. Weakened intestinal motility associated with age-related changes led to the accumulation of gases and the appearance of bowel rumbling. This symptom has no diagnostic significance since it is the norm for a patient 84 years old.
- Genitourinary System. Foley to gravity drains cloudy yellow urine. A dark yellow, almost brown color may indicate an increased bilirubin content. This occurs with the massive destruction of red blood cells after infections and inflammation.
- Skin and Musculoskeletal. The patient has an undated Tegaderm on her coccyx. Her right side is weaker than her left, but she does grip to command with her left hand. The patient has a decrease in strength and increased fatigue of the muscles of the upper extremities.
- Psychosocial. The patient looks at the nurses when they call her name, but they cannot understand her when she tries to talk. She has a deterioration in some areas of cognitive functions, such as articulation. Most likely, this is the result of a weakening of the laryngeal muscles.
Missing Data
Data that is missing that would be beneficial to make stronger conclusions about the patient’s condition includes computed tomography of the urinary organs, the results of excretory urography and ultrasound examination.
Conclusions
Based on the survey data, most of the patient’s systems are within the normal range of acceptable changes. However, the state of the genitourinary system is of concern, the symptoms of pathologies in which are critical and life-threatening. They indicate acute or chronic diseases of the urinary organs.
Most Significant Pathophysiological Process
Etiology
The main risk factors and causes for the development of urosepsis are urinary tract obstruction at any level, congenital uropathies, neurogenic bladder as well as endoscopic interventions on the urinary tract (Prescott & Angus, 2018). Elderly patients, to the group to which this patient belongs, are at the greatest risk of developing urosepsis.
Pathology
The pathogenesis of septic lesions, in this case, is determined by a complex and close interaction of three factors: the pathogenicity of the microorganism, the state of the primary focus of infection and the immunoreactivity of the organism. The development of organ-system damage in the patient is primarily associated with the uncontrolled spread of endogenous proinflammatory mediators from the primary focus of infectious inflammation (Gyawali et al., 2019).
Clinical Manifestations
There is a life-threatening organ dysfunction which is caused by a violation of the regulation of the response to urinary tract infection (Levy et al., 2018).
Diagnostic Tests
This disease is diagnosed using a general urine and blood test, as well as sonography, contrast radiography and CT urography (Levy et al., 2018). As alternative or additional diagnostic methods, MSCT of the kidneys, MSCT cystourethrography, and MRI urography can be recommended (Gyawali et al., 2019). To determine the pathogen, urine is seeded for microflora and a three-time bacteriological seeding of blood is performed.
The rationale for Abnormal Data
Ultrasound of the retroperitoneal space allows to detect of morphological changes in the accumulation of pus (Cecconi et al., 2018). However, the patient’s stomach is soft; this may indicate the initial stage of the disease.
Nursing Plan of Care
Clinical Practice Guidelines
Clinical practice guidelines prescribe the treatment of urosepsis with active infusion and anti-shock therapy and tricyclic glycopeptides, which will fight the focus of infection (Paoli et al., 2018). As auxiliary measures, the authors recommend raising immunity through immunoglobulins and immunomodulators, and blood purification by introduction of plasma substances.
Evaluation of Medical Therapy
Although with late diagnosis and ineffective therapy, urosepsis is characterized by a high probability of death, medical therapy can significantly reduce mortality. The effectiveness of treatment increases significantly when combining empirical and targeted antibiotic therapy.
Rationale for Medical Orders
The main tasks in urogenic septic conditions are elimination of the pathogen, correction of multiple organ disorders, and restoration of homeostasis. Taking into account the severity of the patient’s condition, medical orders are recommended (Cecconi et al., 2018). Etiotropic treatment of urosepsis involves effective rehabilitation of the infectious focus and adequate antibacterial therapy.
Medications
Identification of Questionable Orders
Given the elderly age of the woman, it is necessary to verify with the health care provider which antibiotics can be used for 84-year-old patients (Cecconi et al., 2018).
Legal and Ethical Issues
Legal issues that have been identified in the case relate to the need to start treatment urgently. However, it is not possible to obtain consent from the patient, and her relatives are not in the hospital. On the one hand, it is impossible to start treatment without getting consent, but on the other hand, waiting can lead to a deterioration of the patient’s condition (Cecconi et al., 2018). Ethical issues that have been identified in the case relate to the prescription of expensive drugs to the patient, the purchase of which she may not be able to afford.
The stakeholders are doctors, nurses and patients. Doctors and a nurse should make a decision regarding the start of treatment and prescribing the necessary medications, and the patient should try to assist them and follow the instructions as far as possible.
The nurse should address the issues by making a phone call to the patient’s relatives and discussing controversial issues with them.
References
Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. The Lancet, 392(10141), 75-87.
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., & Levy, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(4), 1181-1247.
Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7(7), 1-13.
Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Medicine, 44(5), 925-928.
Paoli, C. J., Reynolds, M. A., Sinha, M., Gitlin, M., & Crouser, E. (2018). Epidemiology and costs of sepsis in the United States: An analysis based on timing of diagnosis and severity level. Critical Care Medicine, 46(12), 1889-1897.
Prescott, H. C., & Angus, D. C. (2018). Enhancing recovery from sepsis. The Journal of the American Medical Association, 391(2), 62-75.