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Joe G.: Man Hospitalized with Pyelonephritis

Ronda Tippie RN, BSN
Nurse case manager
William S. Middleton Memorial Veterans Hospital
Madison, Wisconsin

Kathleen Sullivan, RN, BSN
Nurse case manager
William S. Middleton Memorial Veterans Hospital
Madison, Wisconsin
Marcia Dobrick, RN, BA
Nursing ADPAC/BCMA Coordinator
William S. Middleton Memorial Veterans Hospital
Madison, Wisconsin

Information Obtained during the Hospital Admission:

Joe G., a 67-year-old man, lived with his wife, and worked part time as a greeter at a discount department store.  He smoked ½ pack of cigarettes per day for about 20 years. Before Mr. G was admitted to the hospital, his wife called the telephone triage line to report that he was nauseated and vomiting, and had an oral temperature of 102.1° F. She said that he had a decreased appetite, painful urination, and left flank pain for the previous three days. His pain was not relieved by aspirin. The telephone triage nurse advised him to come to the urgent care clinic for further evaluation.  After the physical examination, the resident physician reviewed the results of the urinalysis and culture and sensitivity, complete blood count, and chemistry profile.  The blood culture was still pending. The physician diagnosed pyelonephritis, and admitted Mr. G for pain control, intravenous (IV) fluids, and antibiotics until he could tolerate treatment by mouth.

The nurse assessed Mr. G when he arrived on the medical unit.  His temperature had increased to 102.5° F, his heart rate was 100, his respiratory rate was 20, and his blood pressure was 136/84.  His pain score was 7 on a 0 to 10 pain scale with 10 being the most severe. His color was normal, and his skin was warm and moist.  He was ambulating, but splinting his left flank. He voided 220 ml of cloudy urine.
Mr. G was restless, and said he wanted to go outside to smoke a cigarette before the nurse started the IV. However, the hospital did not sell cigarettes, and Mrs. G had taken her husband’s cigarettes and belongings home.

The nurse and Mr. G reviewed his diagnosis, laboratory results, treatment plan, and medications. The nurse urged him to begin his IV right away, and offered to talk to the doctor about helping him stop smoking during his hospitalization. Mr. G said he knew he should stop for health reasons, his wife's encouragement, and the statewide smoking ban. He was not familiar with stop smoking programs.

The nurse adjusted the bed and pillows in a position that was the most comfortable for Mr. G, inserted a peripheral intravenous line, and gave morphine, 1 mgm IV. The morphine could be repeated every 2 hours as needed for severe pain.  When his nausea subsided, he could receive clear liquids by mouth and hydrocodone/acetaminophen (Vicodin) 1 tablet as needed for pain. The nurse gave the initial dose of ceftriaxone (Rocephin), 1 GM IV piggy back. They discussed the therapeutic and side effects of ceftriaxone which was scheduled to be given every 24 hours. The nurse gave him some ice chips and explained Intake and Output.

The nurse noted no problems with the IV site, or side effects from the ceftriaxone. The intravenous morphine increased Mr. G's comfort; his face became more relaxed and he moved with less guarding. The nurse oriented Mr. G to the unit, and explained the hospital comfort rounds. During those hourly rounds, nurses offer assistance with positioning, pain management, assistance getting to the bathroom, and assessment of his response to treatment. The nurse placed his call light and urinal within reach, and raised his side rails. He was instructed to request help if he needed to get out of bed.

Application of the Omaha System:

(Interventions reflect care provided by an RN on a medical unit; ratings were documented during admission care. Medical diagnoses and ICD-9 codes are also documented in charts.)

Domain: Physiological

Problem: Pain (high priority)

Problem Classification Scheme:
Modifiers: Individual and Actual
Signs/Symptoms of Actual:
  • expresses discomfort/pain
  • elevated pulse/respiration/blood pressure
  • compensated movement/guarding
  • facial grimaces
     
Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:
  • signs/symptoms-physical (evidence of pain)
Category: Treatments/Procedures
Targets and Client-specific Information:
  • positioning (initially, every hour, as needed)
Category: Surveillance
Targets and Client-specific Information:
  • signs/symptoms-physical (location/left flank, pain scale, vital signs, non-verbal cues)
     
Problem Rating Scale for Outcomes
Knowledge: 2-minimal knowledge (did not associate pain with infection that required treatment)
Behavior: 2-rarely appropriate behavior (used aspirin and splinting for last 3 days)
Status: 2-severe signs/symptoms (pain scale=7; pain for 3 days, unrelieved by aspirin and interfered with daily activities)

Problem: Urinary function (high priority)

Problem Classification Scheme:
Modifiers: Individual and Actual
Signs/Symptoms of Actual:
  • burning/painful urination
  • hematuria/abnomal color
     
Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:
  • anatomy/physiology (normal urinary function/infection and disease)
  • laboratory findings (blood and urine results; blood culture pending)
  • signs/symptoms-physical (intake and output why/how)
Category: Surveillance
Targets and Client-specific Information:
  • laboratory findings (blood and urine results)
  • signs/symptoms physical (intake and output, retention)
     
Problem Rating Scale for Outcomes
Knowledge: 2-minimal knowledge (little knowledge about diagnosis and treatment; receptive)
Behavior: 3-inconsistently appropriate behavior (waited 3 days to seek care)
Status: 2-severe signs/symptoms (required immediate hospitalization)

Problem: Substance use (high priority)

Problem Classification Scheme:
Modifiers: Individual and Actual
Signs/Symptoms of Actual:
  • smokes/uses tobacco products
     
Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:
  • substance use cessation (initiated discussion)
Category: Surveillance
Targets and Client-specific Information:
  • signs/symptoms-mental/emotional (restless)
     
Problem Rating Scale for Outcomes
Knowledge: 3-basic knowledge (aware of restlessness/dangers, but not treatment options)
Behavior: 2-rarely appropriate behavior (smoked 1/2 pack cigarettes per day for 20 years)
Status: 2-severe signs/symptoms (restless, considering smoking cessation)

Problem: Medication regimen (high priority)

Problem Classification Scheme:
Modifiers: Individual and Actual
Signs/Symptoms of Actual:
  • unable to take medications without help
     
Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:
  • medication action/side effects (infusions, purpose/benefits/timing of pain medications and antibiotic)
  • safety (request help to get up)
Category: Treatments and Procedures
Targets and Client-specific Information:
  • medication administration (intravenous medications at admission-morphine 1mgm IV and ceftriaxone 1 GM IV piggy back)
  • medication set-up (inserted peripheral line)
Category: Surveillance
Targets and Client-specific Information:
  • medication action/side effects (response/reactions/changes)
  • signs/symptoms-physical (venapuncture site/patency, vital signs, intake/output)
     
Problem Rating Scale for Outcomes
Knowledge: 2-minimal knowledge (drug names and some details about effects)
Behavior: 3-inconsistently appropriate behavior (agreed to receive IV instead of going for a cigarette)
Status: 2-severe sign/symptoms (morphine-increased comfort, face more relaxed, less guarding; no response from first dose of antibiotic)