1000

A 72-year-old male client is brought to the emergency department (ED) by their caretaker. The caretaker states that the client, normally alert and oriented, became suddenly confused and agitated this morning. Past medical history includes benign prostatic hyperplasia (BPH) and hypertension. Current medications include tamsulosin, captopril, furosemide, and finasteride.

1010

The client is oriented to self only, and speech is incoherent. Client is attempting to get out of bed, reorientation provided, but ineffective. Lung sounds are clear bilaterally. Skin is intact, warm and dry. Abdomen is soft, grimacing noted upon palpation to the suprapubic area. Denies flank or back pain. Bowel sounds are active in all 4 quadrants, last BM was this morning. Foul-smelling urine was noted on an incontinence pad. 20G PIV inserted into the right forearm.

1020

• CBC
• BMP
• Blood cultures x2
• Straight catheterization, 16F catheter for urine collection
• UA/C&S

1010

The client is oriented to self only, and speech is incoherent. Client is attempting to get out of bed, reorientation provided, but ineffective. Lung sounds are clear bilaterally. Skin is intact, warm and dry. Abdomen is soft, grimacing noted upon palpation to the suprapubic area. Denies flank or back pain. Bowel sounds are active in all 4 quadrants, last BM was this morning. Foul-smelling urine was noted on an incontinence pad. 20G PIV inserted into the right forearm.

1030

Straight cath completed, client tolerated well. 16F silicone catheter used with aseptic technique, no resistance was met during insertion of the catheter. Output of 250 mL of cloudy, yellow malodorous urine noted. UA, CBC, and blood cultures x2 collected and sent to the lab.

1010

The client is oriented to self only, and speech is incoherent. Client is attempting to get out of bed, reorientation provided, but ineffective. Lung sounds are clear bilaterally. Skin is intact, warm and dry. Abdomen is soft, grimacing noted upon palpation to the suprapubic area. Denies flank or back pain. Bowel sounds are active in all 4 quadrants, last BM was this morning. Foul-smelling urine was noted on an incontinence pad. 20G PIV inserted into the right forearm.

1030

Straight cath completed, client tolerated well. 16F silicone catheter used with aseptic technique, no resistance was met during insertion of the catheter. Output of 250 mL of cloudy, yellow malodorous urine noted. UA, CBC, and blood cultures x2 collected and sent to the lab.

1105

UA results received, provider notified. Plan to admit the client to IMC due to delirium secondary to UTI.

1110

• Admit to intermediate care unit
• Vital signs q1h
• CBC, BMP daily
• Notify provider for: T> 101.5°F (38.7°C), HR >120, BP <90/60 or >180/110, O2 sat< 92%
• Monitor I&O q1h
• Ceftriaxone 1g IV over 30 minutes daily
• Infuse 0.9% normal saline at 75 mL/hr
• Acetaminophen 650 mg PO every 8 hrs prn headache/fever/pain

1010

The client is oriented to self only, and speech is incoherent. Client is attempting to get out of bed, reorientation provided, but ineffective. Lung sounds are clear bilaterally. Skin is intact, warm and dry. Abdomen is soft, grimacing noted upon palpation to the suprapubic area. Denies flank or back pain. Bowel sounds are active in all 4 quadrants, last BM was this morning. Foul-smelling urine was noted on an incontinence pad. 20G PIV inserted into the right forearm.

1030

Straight cath completed, client tolerated well. 16F silicone catheter used with aseptic technique, no resistance was met during insertion of the catheter. Output of 250 mL of cloudy, yellow malodorous urine noted. UA, CBC, and blood cultures x2 collected and sent to the lab.

1105

UA results received, provider notified. Plan to admit the client to IMC due to delirium secondary to UTI.

1145

Client received the first dose of ceftriaxone. No adverse reactions were noted.

Day 2 0705

Client is alert and oriented to self and place. He appears calm, but occasionally attempts to exit the bed without assistance. Client’s caretaker is at the bedside. Lung sounds are clear bilaterally. Skin is warm, dry, and intact. Radial and pedal pulses 2+. 1+ edema noted to bilateral lower extremities. Abdomen is soft and bowel sounds are active. Concentrated urine noted in bedside urinal. Client denies pain to the suprapubic area or discomfort with urination.