University of Newcastle: NURS6450 Symptom Management Case Study

This presentation analyzes a case study involving an elderly male patient admitted to a nursing home due to impaired mobility and a history of multiple health issues, including catheter-associated urinary tract infection (CAUTI) and delirium. The presentation outlines the patient's condition, medical history, and the etiology of delirium as a symptom of CAUTI. It explores diagnostic tools such as dipstick tests and microscopic examinations, along with nursing assessments, and identifies suboptimal nursing interventions, including the doctor's lack of physical examination and the nurses' failure to follow the clinical reasoning cycle. Furthermore, the presentation proposes preventative and management strategies, such as improved nursing home regulations, staff training, and enhanced medical protocols, including timely catheter removal and hand hygiene. The presentation concludes by detailing the steps an advanced practice clinician would take to improve the patient's symptom management, including assessing for systemic inflammatory response syndrome, providing quality care, and implementing dietary changes. The presentation emphasizes the importance of proactive interventions to prevent similar incidents and improve patient outcomes.

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