Running electrolyte imbalance and if they need to be

Running head: SEPSIS AND HYDRONEPHROSIS 1

Sepsis And Hydronephrosis
Richa Prasad
Chamberlain University
NR 341 Complex Adult Health
Professor Stocker

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SEPSIS AND HYDRONEPHROSIS 2

Patient demographics

Patient Initials: R. D.
Room: 209
DOB: 03/15/1965
Age: 53

Gender: F
Dated Admitted: 11/27/2017
Resuscitation Status: Full Code
Allergies: NKDA
History of present illness:
Kidney Stones-2012
Relevant past medical and surgical history
Kidney stones-2012- No surgeries
Hysterectomy
Reasons for Admission: Flank Pain, Back Pain, difficulty urinating, decreased urine output.
Medical Diagnosis r/t this admission: Sepsis, Hydronephrosis, UTI, Urinary Retention.
Surgery for this Admission: Nephrostomy tube
Other Medical Diagnosis: High Blood Pressure
Significant Assessment:
Vital Signs:
11/27/2017- 05.28AM
BP: 112/70
Temp: 101.1

SEPSIS AND HYDRONEPHROSIS

3

RR: 24
Pulse: 94
SPO2: 92%

07.40AM

BP: 116/77
Temp: 99.1
RR: 20
Pulse: 90
SPO2: 90% (2LNC)

FOCUSED ASSESSMENT:

09.30AM

BP: 99/68
Temp: 100.1
RR: 24
Pulse: 126
SPO2: 95% (2LNC)

11.00AM

BP:118/80
TEMP: 98.9
RR:2O
PULSE: 76
SPO2: 98%(2LNC)

Patient is alert and oriented x 4. Pupils are equal, round and reactive to light. Patient’s skin is dry
and warm. Pt reports slight cough. Lung sounds are clear upon auscultation. Pt reports severe
back pain and flank pain and requested pain medication for pain relieve. Pt has a urinary catheter
which is draining dark urine. Pt reported difficulty urinating before the urinary catheter was
placed. Active bowel sounds in all four quadrants upon auscultation. Patient states she feels tired
and wants to sleep most of the time. Pt is NPO status due to upcoming procedure. Patient will be
going in for placement of a nephrostomy tube placement in order for urine drainage.

Laboratory and Diagnostic Tests:
Blood culture:

SEPSIS AND HYDRONEPHROSIS 4

This will detect the bacteria that are present in the patients’ blood and also evaluates the
susceptibility to antibiotics.
Urinalysis-Positive for leukocytes
Identifies if the source of infection is urinary tract infection-Pt does have a UTI.

WBC:

11/26/2017-13.2 H
11/27/2017-14.2 H
Indicates an infection that the patient may be having. For this patient, the WBC is elevated which
is due to the sepsis and also the UTI.
Platelet Count: 300,000( Normal)
To access for thrombocytosis or thrombocytopenia
PT: 11 seconds( Normal)- to test for the coagulation system.
PTT: 22 seconds(Low)-to test for the coagulation system
Creatinine level: 2.4(High)- checks how well the kidneys are function and filtering waste
products.
BUN: 28 ( High)-checks how well the kidneys are filtering the waste products.
Lactic Acid: 4.5(High)-this indicates that patient has sepsis and has a severe inflammatory
response.
Sodium-135(To monitor electrolyte imbalance and if they need to be replaced)
Potassium-3.6(To monitor electrolyte imbalance and if they need to be replaced)
Intake: 500ml Output: 260ml
ECG : Normal Sinus Rhythm
This evaluates the heart rhythm or any injury that have occurred.

SEPSIS AND HYDRONEPHROSIS 5

CT scan- Indicates a 5mm stone obstruction the urinary passage.
The CT scan indicates hydronephrosis and stones.
Medications

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Generic: Ciprofloxacin
Brand: Cipro, Cipro XR,
Proquin XR

IV-200-400mg IV every
8-12 hours
Oral-500mg orally every
12 hours

Contraindicated in people with
past hypersensitivity to cipro.
History of myasthenia graves,
use with tizanidine

(WebMD, 2017)

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Quinolone

400mg IV piggy bag x 8
hours

Nausea, Vomiting, Diarrhea,
Abdominal pain, rash,
headache, restlessness
(WebMD, 2017)

Rationale for med administration

Route and Frequency

Nursing Considerations and
Teaching

Patient is on this meds to fight
the sepsis and the Urinary Tract
Infection the patient has.

IV piggy bag x 8 hours

Fluid intake should be
maintained at least 1500-
2000ml/day.
Medication may cause dizziness
and drowsiness. watch for blood
in stool. (WebMD, 2017)

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Generic: Lactated Ringers
Brand: Hartman’s Solution

50ml to 100ml/kg/24
hours

Contraindicated where the
administration of sodium,
potassium, calcium, chloride or
lactate could be clinically
detrimental. (RxList, 2017)

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Isotonic Crystalloid Solution

IV 125ml/hr x 1000ml

CHF, rapid breathing,
pulmonary edema due to over
hydration, fluid electrolyte
imbalances. (RxList, 2017)

SEPSIS AND HYDRONEPHROSIS 6

Rationale for med administration

Route and Frequency

Nursing Considerations and
Teaching

Since patient is NPO status, pt is
receiving lactated ringers for
fluid replacement and also taking
care of nutritional status.

IV 125ml/hr x 1000ml

Always assess level of
dehydration. Auscultate breath
sounds, watch for electrolyte
imbalance. (RxList, 2017)

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Generic: Morphine Sulfate
Brand: Arymo ER, Kadian, MS
Contin

4mg to 10mg every 4
hours for severe pain

Hypersensitivity in the past. If
pt has respiratory depression.
Raised Intracranial Pressure
(WebMD, 2017)

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Opioid Analgesics

4mg IV push every 4
hours for pain

Respiratory depression,
hypotension, bradycardia,
constipation, nausea, vomiting,
urinary retention, flushing,
itching, sweating. (WebMD,
2017)

Rationale for med administration

Route and Frequency

Nursing Considerations and
Teaching

This helps the patient with
treating the severe pain she is
having in lower back and flank
pain.

4mg IV push every 4
hours for pain

May cause drowsiness or
dizziness. Change positions
slowly to minimize orthostatic
hypotension. (WebMD, 2017)

SEPSIS AND HYDRONEPHROSIS 7

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Generic Name: Acetaminophen
Brand Name: Tylenol

325-650mg PO Q4 hr

Hypersensitivity, severe active
liver disease (WebMD, 2017)

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Analgesic.Antipyretic

650mg PO Q6H

Disoriented, rash, angioedema,
dizziness, Toxic epidermal
necrolysis (WebMD, 2017)

Rationale for med administration

Route and Frequency

Nursing Considerations and
Teaching

Used for treatment of fever and
also used to relieve pain for the
patient if the pain level is mild

650mg PO Q6H

Not to exceed recommended
dose. Report rash, unusual
bleeding or bruising, yellowing
of skin or eyes, changes in
voiding patterns. (WebMD,
2017)

Patient centered Problem

-Infection
-Acute Pain
-Risk for Septic Shock
-Risk for bleeding-After nephrostomy tube placement.

Main Patient centered Problem
Infection
3 Nursing Outcomes
-Patient will have clear urine by end of discharge.

SEPSIS AND HYDRONEPHROSIS 8

-Patient will have WBC count in the normal range by discharge.
-Pt’s antibiotics will be administered on time in order to clear the infection.
3 Nursing intervention

–  Administer antibiotics and fluids in a timely manner in order to treat the infection and prevent

it from getting worse.

–  Administer Tylenol for control of fever every 4 hours.

–  Check vital every 2 hours or more frequently to check for any changes from baseline or
worsening of condition.

3 Collaborative Interventions

– Collaborate with health care provider to obtain orders for antibiotics and fluids for aggressive
treatment of the sepsis and UTI.
-Collaborate with urologist and surgeons to getting patient in to clear the obstruction by the stone
in the kidneys.

-Obtain orders for repeat lab work to monitor patient’s improvement.

Interventions-Routine Nursing Management:

-Ongoing monitoring of the patient’s vitals and status
Rationale: This was performed to check patient’s condition and if it is worsening.
-Limited activity for the patient since the patient is having severe pain with movement.
Rationale: This helps control the pain level for the patient.
-Administered pain medications in timely manner.
Rationale: Helped keep pain at a tolerable level for the patient which helped the patient relax a
little.

SEPSIS AND HYDRONEPHROSIS 9

-Administered fluids and antibiotics on time.
Rationale: Administering these helps with treatment of the sepsis.
-Administered Tylenol as needed for treatment of fever.
Rationale: this will help in treatment of fever.
-Patient’s HOB was raised to 30 degrees and patient was moved to a comfortable position.
Rationale: Positional changes helps the patient be at ease and also helps with breathing.
-Administered Lactated ringers as per order.
Rationale: This helps the patient keep a good nutritional balance as they are NPO status for the
procedure.
-Monitor patient’s respiratory status and lung sounds.
Rationale: This helps maintain good airway for patient and also helps monitor fluid intake for the
patient with lung sounds. If there are crackles present, it means that they have retained water.
-Monitor strict intake and output for patient.
Rationale: This helps monitor intake and output of patients to check for level of urinary
retention.
Interventions after surgery.
-Vitals to be performed every 15 mins for the first hour than every hour x 6 hours
Rationale: This helps keep a track of patient status and monitor any blood loss or major changes.
-Monitor site of incision for redness, swelling, and warmth.
Rationale: This will help identify an infection of developing
Collaborative Management
Physician- The physician orders antibiotics, pain medications, and fluids for the patient. The
patient also orders for labs for frequent monitoring of the patient status. The antibiotics help treat

SEPSIS AND HYDRONEPHROSIS 10

the infections, pain medication treats pain and fluids helps with fluid and nutritional
maintenance.
Pharmacist- the pharmacy helps deliver medications that are ordered for the patient on time so it
can be administered to the patient especially for the ciprofloxacin.

Radiologist/Radiography- They perform the CT and X-ray in order to diagnose the patient’s pain
and location of the stone obstruction.
Laboratory- Helps obtain labs or running tests as soon as possible and releasing results.
Surgeon- Explains the procedure to the patient and obtains consent for the procedure.
Therapeutic Modalities

Patient is on 2 liters nasal cannula oxygen therapy. Pt’s Oxygen saturation seems to lowered with
increased lowered back and flank pain. The nurse requires knowledge on which oxygen mask to
use and which one would be best suited for the patient. As nurses, we are able to monitor the
patients response to the oxygen therapy and make necessary changes.

Monitoring vitals for the patient and recognizing any changes that is alarming and that needs to
be reported to the physicians so interventions can be taken or performed in order to maintain
health of patient. All other ID team members are not always there with the patent and would not
be able to see any alarming signs as they don’t know the patient like their nurse does.
Therapeutic Communication is provided to the patient but the nurse. The nurse is the one who is
closest to the patient and communicates with the patient. The patient is more comfortable sharing
concerns with their nurse than anyone else. Inquiring about the patient concerns and getting right
answers for them gives them a sense of wellbeing.

SEPSIS AND HYDRONEPHROSIS 11

Nursing Role Reflection

Interaction with the health care team has great benefits to the patient care. The interaction that I
had experience between all the health care team members was exceptional. The physician was
available whenever the patient or their family members had questions for the nurse. Sometimes it
was difficult to get a hold of the physician as he was busy with other patients. The nurse was able
to contact the provider easily when there were some new orders needed or if there was any order
changes that was required. The nurse for the patient was also available for answering questions
that the family members had. She was able to contact the needed person, who would be able to
answer talk to the patient and her family. I had also helped with communication with the family
and patient and inquiring about the concerns or questions they had. The way the members of the
organization communicated with each other and family members was very productive and the
process of getting patient ready for the procedure after diagnosis of the 5mm stone obstruction
was very effective and efficient.

Some recommendation for improving interdisciplinary collaboration is by improving in-person
communication which empowers the caregivers to communication comprehensively and
accurately with other members. This also helps the healthcare providers to fully collaborate even
though they don’t work side by side. It is also recommended that all members of the team for the
care of patient needs to be on the same page so they can contribute their expertise to meet the
complex needs of the patient. (Nursing Executive Center, 2017)

Another recommendation is that each member of the team should be aware of their knowledge
and should learn to value and manage diversity-these differences are essential for the effective
collaborative process and outcomes and together they can develop constructive conflict
resolution skills. (Gardner, 2005)

SEPSIS AND HYDRONEPHROSIS 12

Professional Development:

My experience with this patient has been very rewarding. I have seen how the nurse was
able to communicate with the patient and family members and also the health care team in order
to be able to improve health for the patient. I have learnt in class that effective communication is
beneficial, but in this clinical setting with this patient I have witnessed it. This fast
communication between the nurse and the physician and also getting the surgeon and other
health care team members like radiology department, lab specialist,etc helped the patient get into
surgery as soon as possible to get the nephrostomy tube in place temporarily. I believe that
advocating for the patient is one of the most important roles of the patient.

We as nurses have to be alert as to what can benefit and harm the patient. We are the ones
who can tell if the patient’s health status is improving or if it is getting worse and recognizing
this will help us initiate proper treatment and interventions for our patients. Once I am a nurse, I
want to be as effective as the nurse that I had followed. I would contact the provider when
needed. I would get the necessary orders from them in order to help my patient. Also when we
send labs, we need to communicate with the lab if we do not get results. Also communication
with the nurses from other department such as the surgery team nurse can save us time as we will
get the patient ready for transport and when they come to transfer the patient, the process is
easier and faster.

I believe taking care of this patient has taught me a lot in terms of obtaining orders,
obtaining vitals and monitoring any changes from their baseline and making necessary changes
in interventions to promote the patients’ health.

SEPSIS AND HYDRONEPHROSIS

13

References:
Gardner, D. (January 31, 2005). “Ten Lessons in Collaboration”. OJIN: The Online Journal of

Issues in Nursing. Vol. 10 No.1, Manuscript 1.
Nursing Executive Center, 2017. Strengthening Interdisciplinary Collaboration. Retrieved from

https://www.advisory.com/Research/Nursing-Executive-

Center/Studies/2012/Strengthening-Interdisciplinary-Collaboration
RxList (2017). Lactated Ringers. Retrieved from https://www.rxlist.com/lactated-ringers-

drug.htm
WebMD(2017). Ciprofloxacin. Retrieved from https://www.webmd.com/drugs/2/drug-

7748/ciprofloxacin-oral/details
WebMD(2017). Morphine Sulfate. Retrieved from https://www.webmd.com/drugs/2/drug-327-

819/morphine-oral/morphine-oral/details
WebMD(2017). Tylenol. Retrieved from https://www.webmd.com/drugs/2/drug-7076/tylenol-

oral/details