Lucille Howard, age 78, is in the hospital for a severe urinary tract infection (UTI). She has a history of urinary retention and UTIs. She is overweight, has a history of heart failure, and is allergic to many medications, including several antibiotics. Twenty-four hours ago she had severe nausea and vomiting and was prescribed nothing by mouth (NPO). She has an IV catheter inserted in her left arm, infusing D5 ½ NSS at 75 mL/hr. While caring for Ms. Howard, you notice that she begins to have some coarse audible breath sounds and difficulty breathing. She reports pain in her abdomen.
Prescribed Interventions
- Intravenous fluids: D5 ½ NSS at 75 mL/hr
- Ciprofloxacin 200 mg IV q12h
- NPO
- Strict I&O
Developing Clinical Reasoning and Clinical Judgment
- What are possible causes of Ms. Howard's current symptoms?
- What actions will you take?
- How would you identify the source of her current symptoms?
Suggested Responses for Integrated Nursing Care
- There are several potential causes for Ms. Howard's symptoms. In light of her drug sensitivities, she may be allergic to the ciprofloxacin. Allergic responses can include difficulty breathing as well as itching and a rash. Another source of her symptoms could be related to her heart problems. People with heart problems can easily become overloaded with fluid. Symptoms of fluid overload, a common problem for patients with heart failure, include crackles in the lungs, abnormal heart sounds, and possibly edema.
- To determine the cause of Ms. Howard's symptoms, you need to perform several assessments. First, obtain vital signs (refer to Chapter 2), auscultate her heart and lung sounds and palpate her abdomen (refer to Chapter 3). Assess for edema. Also assess for a rash on her skin, and ask her if she has any itching. Review her voiding history and volume of urine per episode of voiding.
- If her heart and lung sounds are normal, but her abdominal discomfort persists, she may have to urinate. Review the method she has been using to void. Ms. Howard is overweight and positioning on a bedpan may be difficult and is not conducive to emptying of her bladder. Arrange for and encourage her to get out of bed to void; use of a bedside commode is probably the best intervention, as she is experiencing some difficulty breathing and probably has decreased energy related to her acute illness (refer to Chapter 12). Consider checking postvoid residual to confirm she is emptying her bladder (refer to Chapter 12). Consult a safe patient handling algorithm to help you make decisions about safe patient handling and movement (refer to Chapter 9). Utilize appropriate transfer devices and the assistance of others when assisting Ms. Howard out of bed.
- If Ms. Howard seems to be emptying her bladder and the postvoid bladder scans reveal minimal retention, her discomfort could be related to the UTI. Collaborate with the health care provider regarding appropriate analgesia.
- You should also review the patient's intake and output, for the most recent hours and for the last 24 hours (refer to Chapter 16). Currently, Ms. Howard is getting 75 mL/hr of IV fluid. She should be voiding an average of at least 30 mL/hr, the least amount of urine you would expect to see in an hour (30 mL). You could weigh the patient and compare today's weight with her admission weight (refer to Chapter 3). The record of a patient's daily weight may more accurately depict fluid balance status, due to possible numerous sources of inaccuracies in fluid intake and output measurement. Weigh the patient at the same time every day. If Ms. Howard's input is higher than her output, she is at risk for overload. New or worsening edema or significantly increased body weight in 24 hours indicates an accumulation of fluid related to fluid overload or worsening heart failure.
- If Ms. Howard is having an allergic reaction, hold any dose of the ciprofloxacin that may be due, follow anaphylaxis protocol, and notify the health care team. If she is beginning to have problems with fluid overload due to her heart problems, reduce the IV rate to a keep open rate (20 to 40 mL/hr), and consult with the health care team regarding further intervention. Continue to monitor Ms. Howard until you are certain she is stabilized and her symptoms have resolved.