Clinical Management | Presentation

CLINICAL
MANAGEMENT

INTRODUCTION: patient’s
condition
 Reasons for admission-Impaired mobility and catheter
associated urinary tract infection
 Past hospital admissions and medical history-
 Pneumonia
 Confusion or delirium
 Abdominal pain
 Disorientation leading to falls and reduced mobility
 Atrial fibrillation
 hernia
 Depression and anxiety
 Colorectal cancer
 Colostomy and triple aneurysm in the abdominal aorta
Surgeries that he has undergone in the past-
 Stent implantation for ischemic heart disease and
 Prostatectomy with insertion of a suprapubic catheter.
Fig 1: Prosatectomy
(Cancerresearchuk.org, 2020)

INTRODUCTION
Catheter-associated urinary tract
infection (CAUTI):
• Catheter stuck inside and could
not be removed earlier
• Forceful removal of previous
catheter
• Insertion of new catheter
Symptoms - Infection at the site of
inserted catheter
• Redness and swelling on the
site with bloody pus oozing out.
• Delirium (Armbruster et al.,
2017) Fig 2: Catheter insertion
(Healthywa.wa.gov.au, 2020) Fig 3: biofilm formation in indwelling
catheter (Azevedo et al., 2017).

AETIOLOGY OF DELIRIUM AS A
SYMPTOM OF CAUTI
• Indwelling catheters are one of the causes of delirium in
older people
• Unhygienic hands placing the indwelling catheter can
transfer pathogenic bacteria from the hands to the
catheter .
• People with dementia are at risk of infection caused by
catheter
• Due to dementia patients forget to wash their hands
properly before touching the catheter and increasing risk
of urinary tract infection (Alzheimers.org.uk, 2020)

• Delirium can be caused
various surgical methods such
as placing of catheter in the
urinary tract in elderly (Bo et
al., 2019).
• Some studies found that
delirium was an early sign of
CAUTI.
Fig 5: post-operative neurologic
disorders (Mahanna-Gabrielli et al.,
2019)
AETIOLOGY OF DELIRIUM AS A
SYMPTOM OF CAUTI

DIAGNOSTIC TOOLS TO TEST FOR CAUTI:
DIPSTICK TEST AND MICROSCOPY
For collecting urine sample the following procedure is to be
followed-
Clean the urinary area
Begin urinating
Bring the collection container infront of the urine stream
Collect 1 to 2 ounces of urine
Close the lid of the container
Deliver the container of the sample to the pathologist
Physical and pathologic examination of urine (Mayoclinic.org,
2020).
Observation:
• Visual examination: pus with the urine
• Dipstick test:
pH- basic
Infection- yes
Blood- yes
• Microscopic visualization of leukocytes
and bacteria: leukocyte present along
with bacteria
Fig 6: urine dipstick
(Labtestsonline.org. 2020)

Nursing assessment
 Medical history , physical examination and monitoring vital signs (Rch.org.au, 2020).
 Assessment of specific body site for present the problem of patient X which is CAUTI
and delirium.
 Patient history- prostatectomy leading to indwelling catheter insertion
 Vital signs
 Temperature- above 37°C (having fever)
 Breathing- above 20 breaths per minute (showing tachypnoea)
 Pulse- lower than normal
 Blood pressure – lower than 90/60 mm Hg (low blood pressure and hypotension)

• The doctor entirely ignored the due
date of the catheter changing.
• The nursing staffs removed the stuck
catheter from the body of the patient
without the presence of the doctor.
• The patient infection was not
decreasing and the condition was
deteriorating even after antibiotic
administration.
• The doctor prescribed a painkiller over
the phone. Fig 7: Endone painkiller
prescribed to the patient (Gold
104.3 Melbourne, 2020)
SUB-OPTIMAL NURSING
INTERVENTIONS

• The doctor did not attend the patient
even after further deterioration of the
patient condition.
• No physical examination was done
before prescribing any medicine.
• The nurses did not follow the clinical
reasoning cycle as well, while taking
care of the patient.
Fig 8: Medical Negligence
(Medical Dialogues, 2020)
SUB-OPTIMAL NURSING INTERVENTIONS

For patients with similar symptomatology some preventive and
management measures can be taken to avoid repetition of the same
incidence as this one.
The management strategies that can be developed are the
following:
• The nursing home authority should become more stringent with it’s
rules and regulations.
• The nurses should be given training to manage patients in severe
conditions (Civil Liberties Australia, 2020).
MANAGEMENT STRATEGIES

The medical strategies that should be improved and developed include the
following (Government of South Australia, 2020) :
• Ensuring the need for urinary catheter should be assessed at the
beginning.
• Catheter should be removed as soon as the requirement is no longer
needed.
• Before inserting the catheter the hands should be washed properly to
maintain hand hygiene so that no infection occur from there.
• Prompt action should be taken in case of any infection or sepsis develops.
MANAGEMENT STRATEGIES

The immediate steps that I would have taken as an advanced
practice clinician to improve the condition of the patient
include:
• Identify the symptoms of catheter associated urinary tract
infection which the patient showed in the form of delirium
(Centers for Disease Control and Prevention, 2020).
• I would have visited the patient and asses him on the basis of
systemic inflammatory response syndrome.
• I would have ensured proper optimum quality care to be
provided to the patient.
• I would prepare a diet chart for him which would be
containing Vitamin C rich food and cranberry juice
(Montorsi et al., 2016).
• Regular toileting is the next thing I would arrange for. Fig 9: Food rich in Vitamin C (Plyvine
Catering, 2020)
IMPROVING THE SYMPTOM
MANAGEMENT

REFERENCES
Alzheimers.org.uk. (2020). Urinary tract infections (UTIs) and dementia. Retrieved 30 March 2020, from
https://www.alzheimers.org.uk/sites/default/files/pdf/urinary_tract_infections_utis_and_dementia.pdf
Armbruster, C. E., Prenovost, K., Mobley, H. L., & Mody, L. (2017). How Often Do Clinically Diagnosed Catheter-
Associated Urinary Tract Infections in Nursing Homes Meet Standardized Criteria?. Journal of the American Geriatrics
Society, 65(2), 395–401. https://doi.org/10.1111/jgs.14533
Azevedo, A. S., Almeida, C., Melo, L. F., & Azevedo, N. F. (2017). Impact of polymicrobial biofilms in catheter-associated urinary
tract infections. Critical reviews in microbiology, 43(4), 423-439.
Bo, M., Porrino, P., Di Santo, S. G., Mazzone, A., Cherubini, A., Mossello, E., ... & Filippini, C. (2019). The association of
indwelling urinary catheter with delirium in hospitalized patients and nursing home residents: an explorative analysis
from the Delirium Day 2015”. Aging clinical and experimental research, 31(3), 411-420.
Cancerresearchuk.org. (2020). Surgery to remove your prostate gland | Prostate cancer | Cancer Research UK. Retrieved 30 March
2020, from https://www.cancerresearchuk.org/about-cancer/prostate- cancer/treatment/surgery/surgery-remove-
your- prostate-gland

REFERENCES
Centers for Disease Control and Prevention. (2020). Catheter-associated Urinary Tract Infections (CAUTI) | HAI |
CDC. Retrieved 30 March 2020, from https://www.cdc.gov/hai/ca_uti/uti.html
Finucane, T. E. (2020). Bacteriuria in a Patient with Incident Delirium. In Home-Based Medical Care for Older Adults (pp. 29-
33). Springer, Cham.
Gold 104.3 Melbourne. (2020). A Popular Painkiller Been RECALLED Australia-Wide. Retrieved 30 March 2020, from
https://www.gold1043.com.au/newsroom/endone-painkiller-recalled-from-shelves-across-the-country/
Healthywa.wa.gov.au, 2020. Your Suprapubic Catheter. [online] Healthywa.wa.gov.au. Available at:
<https://healthywa.wa.gov.au/Articles/U_Z/Your-suprapubic-catheter> [Accessed 5 April 2020].
HealtLabtestsonline.org. (2020). Urinalysis - Understand the Test & Your Results. Retrieved 30 March 2020, from
https://labtestsonline.org/tests/urinalysis

REFERENCES
Mahanna-Gabrielli, E., Schenning, K. J., Eriksson, L. I., Browndyke, J. N., Wright, C. B., Evered, L., ... & Purdon, P.
(2019). State of the clinical science of perioperative brain health: report from the American Society of
Anesthesiologists Brain Health Initiative Summit 2018. British journal of anaesthesia, 123(4), 464-478.
Mayoclinic.org. (2020). Urinalysis - Mayo Clinic. Retrieved 30 March 2020, from https://
www.mayoclinic.org/tests-procedures/urinalysis/about/pac-20384907
Medical Dialogues. (2020). Maharashtra Medical Council Suspends doctor for medical negligence. Retrieved 30 March
2020, from https://medicaldialogues.in/maharashtra-medical-council-suspends-doctor-for-medical-negligence

REFERENCES
Montorsi, F., Gandaglia, G., Salonia, A., Briganti, A., & Mirone, V. (2016). Effectiveness of a combination of cranberries,
Lactobacillus rhamnosus, and vitamin C for the management of recurrent urinary tract infections in women: results of
a pilot study. European urology, 70(6), 912-915. https://doi.org/10.1016/j.eururo.2016.05.042
Plyvine Catering. (2020). 10 Foods Rich in Vitamin C | Plyvine Catering. Retrieved 30 March 2020, from
https://plyvinecatering.co.uk/10-foods-rich-in-vitamin-c/
Rch.org.au, 2020. Clinical Guidelines (Nursing) : Nursing Assessment. [online] Rch.org.au. Available at:
<https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/> [Accessed 5 April 2020].

THANK
YOU!