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Discussion 1: Describe your clinical experience for this week

Did you face any challenges, any success?

This week in the clinical setting, we faced a challenge with a 69-year-old female presenting to the clinic with increased urinary frequency, weakness, burning during urination, dizziness, and changes in mental status with insomnia for two weeks. The challenge was determining the etiology of her acute status change and prescribing the appropriate treatment with age consideration and comorbidities. Another challenge was having to rely on a family member to ascertain details about a patient’s HPI when they present with an alteration in mental status.

Describe the assessment of a patient.

(S). Patient present with history of type 2 Diabetes Mellitus and is on Metformin 500 mg by mouth once daily. Patient had hgA1c performed one month prior with a value of 6.2. Patient presents with daughter with CC: “Mom has started having memory problems and starts talking nonsense for the past two weeks.” The daughter states that the patient has not been drinking water like she is supposed to, but her blood sugars have not gone above 180. She reports that she has noticed her mother’s urine is very dark and “smells foul.” Denies urinary incontinence but has observed her mother complaining of lower back pain. Denies allergies to medications, latex, or environment.

(O). Vital Signs: T. 98.5 P. 101. RR 20 BP: 150/88 (left arm, sitting). Ht. 5’4 Wt. 170. BMI 29.2 Patient is AAO x 2 today (person and place). General appearance is well nourished and appropriately dressed. Speech is coherent but disorganized thoughts noted. She presents with pelvic pain during light palpation of abdominal examination. No other abnormal objective findings noted at this time.

(A). Diagnosis: Urinary Tract Infection (UTI). Differential Dx: (1.) Diabetes Mellitus Type 2. (2.) Pelvic infection. (3.) Interstitial cystitis. (4.) Pyelonephritis.

(P). According to Cash & Glance (2019), over-diagnosis of UTI in the geriatric population has led to unnecessary hospitalization for more than 40% elderly patients. Atypical presentation of UTI in the elderly include absence of fever, worsening mental or functional status, dizziness, anorexia, fatigue, and weakness (Kennedy-Malone et al., 2019). A urinalysis with reflex culture, CBC, and CMP were collected. Empiric treatment for UTI should be avoided in this patient population unless the patient presents with at least two clinical indicators such as fever and chills, new or increased dysuria, frequency or urgency, worsening mental status, new or increased UI, or new flank pain (Cash & Glance, 2019). Pt. will be prescribed Bactrim 160mg/800mg one tablet, twice daily x 7 days.

My preceptor decided to perform a repeat urine culture in one week with follow up evaluation for effectiveness of medication regime and implementation of proper hygiene as directed to patient. Teaching was provided to daughter to continue monitoring blood glucose, adherence to medication regime, diet, exercise, and to monitor for improvements in mental status.

What did you learn from this week’s clinical experience that can be beneficial for you as an advanced practice nurse?

I learned that an adequate history and comprehensive physical will allow the clinician to develop a differential diagnosis and appropriate plan of care. On my initial assessment, I assumed the patient was experiencing hyperglycemia related polyuria. Based on urine dipstick studies, patient’s presentation, and review of systems, we were able to determine the patient was suffering from a urinary tract infection based on improper hygiene. The patient’s daughter was able to inform us that the patient normally has improper hygiene and wipes from back to front. It is important to monitor all aspects of patient care with age-appropriate considerations. Managing the patient’s diabetes, altered mental status, safety, fall precautions, adequate fluid hydration, and adherence to dietary regime is important.

References

Cash, J. C., & Glass, C. A. (2019). Adult-gerontology practice guidelines. Springer Publishing Company, Llc.

Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.