NUR 612 WK 5 Clinical Manifestation of Urinary Tract Discussion

Discussion Week #5: Chief Complaint: Foul smelling urine, incontinence, restless.

What additional subjective data are you seeking to include past medical history, social, and relevant family history?

According to Cash & Glance (2019), geriatric patients may not present with the classic signs of urinary tract infections and may present with fever, incontinence, and mental confusion. A detailed assessment of his chief complaint is crucial for proper diagnosing. I would seek data to further clarify his urinary symptoms such as difficulty urinating, hesitancy, decreased force of stream, frequency with decreased amount, dribbling, dysuria, hematuria or nocturia. I would establish qualifiers such as onset, frequency, and possible contributing factors. Does the patient experience any fever, chills, flank or suprapubic pain?

I would explore details regarding previous UTIs he experienced, including the date and treatment of the most recent episode. I would inquire if his past medical history included any prostate issues (other than enlargement and if this patient has been treated by a urologist in the past. I would question if this patient’s ORIF of the right hip was directly related to a fall subsequent to urinary incontinence or increased dementia.

A thorough review of his medication history, dosages, and adherence needs to be assessed in the subjective data collection. For instance, one side of effect of donepezil is in fact frequent urination and difficulty controlling urination. As part of his social history, I would seek the patient or person providing the information on the patient’s behalf, exactly how much fluids and coffee he consumes and if they have tried decaffeinated, as caffeine is a known diuretic.

According to Kennedy-Malone et al. (2019), assessment of the urogenital system of older adults should include a complete sexual history, including a history of impotence and sexually transmitted infections.

What additional objective data will you be assessing for?

Objective data always begins with review of the vital signs, which may appear normal in elderly patients, requiring the provider to develop the skills to look at the entirety of the patient’s health picture. Understanding that many elderly patients have comorbidities and polypharmacy, should alert the provider to the implications this may have on the patient’s vital signs. Following vital signs, I would assess his general appearance and repeat the mini mental state examination (MMSE), before moving into a comprehensive head-to-toe physical examination.

Objective data collection of the urogenital system of the older male includes examination of the prostate and is conducted with the rectal examination (Kennedy-Malone et al., 2019). Examination begins with inspection and palpation of the genitals for which I would be looking to see if the patient is circumcised, uncircumcised, or phimosis. I would observe for lesions, rashes, chancres, or intertrigo. Physical exam would include palpation of the testes, epididymides, and a rectal exam.

What are the differential diagnoses that you are considering?

Differential diagnosis for this elderly patient would include urinary tract infection with careful watch for systemic symptoms of pyelonephritis, prostatitis or epididymitis, and benign prostatic hypertrophy (BPH) (Hollier, 2018). Additionally, for patients with chronic UTIs, it’s important to not miss signs of disseminated infection, such as endocarditis (Cash & Glass, 2019). Systemic conditions from chronic infection can result in fever, tachycardia, mental status change, and/or hypotension.

What laboratory tests will help you rule out some of the differential diagnoses?

A urinalysis will reveal urine appearance, color, odor, pH, specific gravity, and presence of possible leukocyte esterase or nitrates. A urine culture and sensitivity with specify which organism is present and what treatment it is most susceptible to. I would also perform a CBC, blood culture, and creatinine.

What radiological examinations or additional diagnostic studies would you order?

After a comprehensive gathering of subjective data, objective data, and reviewing laboratory test results, a renal ultrasound or voiding cystourethrogram may be helpful in diagnosis.

What treatment and specific information about the prescription that you will give this patient?

It is imperative for the healthcare provider to complete a comprehensive collection and review of the geriatric patient’s condition and PMH before initiating treatment. Asymptomatic bacteriuria (ASB) is frequently seen in the elderly population, particularly those in long-term care facilities, and is not treated because of colonization. According to Cash & Glass (2019), empiric treatment for UTI should be avoided unless 2 clinical indicators are present: Fever or chills, new onset dysuria, increased frequency, worsening mental or functional status, or new flank or suprapubic pain. For this symptomatic, 82-year-old patient, it is crucial to obtain hospital records and know what antibiotics he has already been given in order to prescribe an alternate antibiotic for which the culture reveals susceptibility. The Beers list is important to utilize in treatment consideration and what to avoid in the elderly patient.

What are the potential complications from the treatment ordered?

Complications of any treatment ordered is the possibility of increased drug resistance if improperly diagnoses or if there is lack of treatment adherence. Other potential complications may include adverse side effects or drug interactions with the patient’s other prescriptions.

What additional laboratory tests might you consider ordering?

If following treatment, the patient’s mental or functional status continues to decline in addition to new or worsening urinary symptoms, fever, chills, or flank pain, a follow up urine culture and possible hospitalization may be necessary (Cash & Glass, 2019).

What additional patient teaching may be needed?

Patient teaching in this scenario must also involve the patient’s care takers and family. They would be instructed to avoid foods that irritate the bladder such as caffeine, alcohol, spicy foods, and citrus. The patient should be on a bladder training routine and have increased supervision for fall prevention. They can be educated on signs and symptoms of worsening infection, sepsis, pyelonephritis, or renal abscess in the elderly patient. Medication adherence is crucial to the success of irradiation of causative agents and they can be instructed to ensure the patient completes the regimen as prescribed.

Will you be looking for a consult?

Given this patient’s long history of chronic UTIs, worsening urological symptoms, and most recent decline in mental status, I would certainly refer this patient to a urologist for evaluation and treatment.

References

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

Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.

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.