Video Case Study - Healthcare-Associated Infection

Nurse Monique begins her shift on a medical-surgical unit caring for Sam, a 78-year-old male who was admitted two days ago for chronic heart failure. After introducing herself, Nurse Monique begins her shift assessment and goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Sam's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Monique recognizes important cues. First, she notices Sam has an indwelling urinary catheter, which is draining cloudy urine. Then, she takes his vital signs and notes his temperature is 100.6 F, or 38.1 C. She palpates Sam's abdomen, which elicits suprapubic pain that Sam rates as a 4 out of 10. He also reports that he didn't have this type of pain until this morning.

Next, Nurse Monique analyzes these cues. She reviews the electronic health record, or EHR, which shows Sam's vital signs during the previous shift were within normal limits and his urine was clear. Nurse Monique knows that due to Sam's increased age and presence of an indwelling catheter, he's at high risk for a health care-associated infection, or HAI, which is an infection that develops from exposure to microorganisms in a health care setting.

Nurse Monique considers these risk factors along with Sam's new onset of fever, pain, and cloudy urine. She suspects that Sam is experiencing a type of HAI known as a catheter-associated urinary tract infection, or CAUTI. Now, using the information Nurse Monique has gathered, she chooses a priority hypothesis of impaired urinary elimination.

Then, she generates solutions to address this hypothesis that will include pharmacologic and nonpharmacologic interventions. She also establishes the expected outcome, that after intervention, Sam's temperature will be within normal range, and his symptoms of CAUTI will improve.

Next, Nurse Monique takes action to implement these solutions. She calls the health care provider to report her assessment findings. The health care provider orders a urinalysis, a urine culture, and prescribes 650 milligrams of acetaminophen by mouth every four hours as needed for pain and fever. While waiting for the pharmacy to approve the new medication, she gathers the supplies needed to obtain the urine specimens and enters Sam's room.

Nurse Monique: The symptoms you're having might be due to a urinary tract infection, so your health care provider has ordered some urine tests, and some acetaminophen for the pain and fever. I also brought a heat pack for your abdomen, which can help you feel more comfortable.

Sam: How did I get a urinary tract infection?

Nurse Monique: Well, when a patient has a urinary catheter, it gives bacteria a pathway to bypass the body's normal defenses and cause an infection. Your health care provider will order an antibiotic to help get rid of the infection, so let's get those samples sent to the lab.

Sam nods in agreement.

Then, Nurse Monique follows her facility's protocol for obtaining the urine specimens. After sending the specimens to the lab, she administers the prescribed acetaminophen using the six steps of medication administration and three checks. Then, she applies the heat pack to Sam's suprapubic area, and delegates routine catheter care to assistive personnel.

An hour later, Nurse Monique reports the urinalysis results to the health care provider who makes the diagnosis of CAUTI and prescribes ceftriaxone 2 grams IV every 24 hours. Once approved by the pharmacy, she prepares the dose and re-enters Sam's room.

Nurse Monique: The tests confirmed you have a urinary tract infection, and your health care provider prescribed an antibiotic called ceftriaxone that'll go through your IV.

Sam: Okay, that sounds fine.

After administering the ceftriaxone, Nurse Monique reassesses Sam's pain, which he now rates as a 2 out of 10. Before leaving the room, she repositions Sam for comfort, reapplies the heat pack, ensures his catheter is draining freely, and places his call light within reach.

Three days later, Nurse Monique evaluates the outcome of her actions. She takes Sam's vital signs and assesses his urine characteristics and pain. His vital signs are within normal limits, including a temperature of 98.2 F, or 36.8 C. Sam states his suprapubic pain has subsided, and he has not needed a dose of acetaminophen for the past two days. Because Sam's temperature is within normal range and his CAUTI symptoms have improved, she determines the desired outcome has been met. Sam will continue to receive the antibiotic until the infection has been eliminated.

Alright, as a quick recap... Nurse Monique recognized and analyzed cues related to Sam's impaired urinary elimination, and then prioritized hypotheses and generated solutions to address this problem. Nurse Monique implemented pharmacologic and nonpharmacologic interventions to address Sam's impaired urinary elimination and evaluated Sam's outcomes and compared them to the expected outcome. Since Sam's temperature is now within normal range and his urinary tract infection symptoms have improved, Nurse Monique determined that the plan of care was successful.