Case Study – Complications Associated with the Urinary System
The Rationale for the Patient Becoming Confused and Combative
The client’s confusion and combativeness could be due to several factors. Firstly, their repeated hypoglycemia, as was highlighted in the admission note, could medically alter their mental state, leading to confusion and agitation. Hypoglycemia arises when blood sugar levels are too low, depriving the brain of fuel, which leads to a state of confusion and combative street behavior (Nakhleh & Shehadeh, 2021). Besides, the client’s blood sugar levels that changed drastically (from 45 to 130) during the documented period could have had an impact on their psychological status. On the other hand, the fact that there is a presence of fever noted by the high body temperature of 103.6 suggests the possibility of underlying infection or inflammatory processes that could cause confusion and agitation in older individuals. Also, the patient is vulnerable to cerebral ischemia or microvascular changes, mainly due to his previous history of hypertension and atrial fibrillation. Therefore, he is more likely to have cognitive impairment and psychological changes.
A Pivotal Decision Made in the ER That Directly Caused the Client’s Worsening Condition
The use of a Foley catheter in the emergency room may have been the cause of the worsening condition. A Foley catheter insertion leads to an increased risk of urinary tract infection (UTI), especially for older adults with other conditions, as argued by Kranz et al. (2020). The cloudy yellow-colored urine drained from the catheter means that the urine had unusual characteristics that could be signs of a UTI. Dutta et al. (2022) indicate that UTIs can trigger systemic inflammation and sepsis, which, in turn, deteriorate cognitive function and trigger confusion and agitation in elderly patients. Thus, the act of inappropriately inserting a Foley catheter without a proper indication and monitoring possibly hurt the client’s health state.
The Type of Incontinence That the Client Had
Based on the given case, the patient faced functional incontinence. Functional incontinence is a condition where an individual experiences difficulty getting to the toilet in time because they have physical or mental impairments but have intact bladder control (Tran & Puckett, 2020). The Foley catheter, which was put in to overcome incontinence and weakness, is a sign that the client was unable to reach the bathroom alone and has some functional limitations. Furthermore, the patient’s confusion and aggressive behavior, which may be linked to frequent hypoglycemia and pyrexia, provoke functional incontinence, which worsens urinary urge recognition and response-ability.
Factors in the Client’s Medical History That Contributed to the Client’s Change in Condition
Multiple pieces of evidence in the patient’s medical history triggered this change. Initially, the patient’s history of diabetes, hypertension, atrial fibrillation, and mild heart failure poses a risk of cardiovascular complications involving decreased consciousness and confusion due to hypoglycemia. In addition to this, the insulin-dependent diabetes of the patient raises the risk of the recurrence of hypoglycemia, especially when the insulin dosage is not properly adjusted or when the meals are skipped (Agrawal et al., 2022). Also, the client’s smoking history and rheumatoid arthritis may encourage the cardiovascular and inflammatory processes, thus making fever and systemic illness more likely. To sum up, the patient’s low-level mobility may lead to a functional decrease and some of the complications, such as retention of urine and pressure ulcers, when they are hospitalized.
How Communication Contributed to the Poor Outcome of the Client
Communication breakdowns among healthcare providers, as shown by delayed recognition of the patient’s deteriorating condition, contributed to the poor outcome. As a case in point, the client’s daughter raised the issue of her mother’s confusion and fever, yet there was a delay in notifying the RN and getting the process of treatment started. Moreover, inadequate interdisciplinary communication among nurses, case managers, and physicians could be one of the barriers to prompt diagnosis and management of the client’s complicated medical conditions, including recurrent hypoglycemia and the possibility of infection. Besides that, the absence of adequate communication about the client’s baseline functional status and limitations in mobility may have led to improper intervention, like inserting a Foley catheter without considering other means of incontinence management in a cognitively impaired individual. Moreover, the LPN’s observation of cloudy yellow urine, a potential sign of UTI, was ineffectively communicated to the rest of the healthcare team, leading to worsening confusion and combativeness in the client. Through the team approach, small changes in the patient’s condition, which could be overlooked, are recognized. Kwame and Petrucka (2021) reiterate that coordination of care and delivery of timely interventions are achieved by communication among healthcare team members to optimize the results.
References
Agrawal, S., Makuch, S., Dróżdż, M., Dudzik, T., Domański, I., Poręba, R., & Mazur, G. (2022). The impact of hypoglycemia on patients with diabetes mellitus: A cross-sectional analysis. Journal of Clinical Medicine, 11(3), 626. https://doi.org/10.3390/jcm11030626
Dutta, C., Pasha, K., Paul, S., Abbas, M. S., Nassar, S. T., Tasha, T., Desai, A., Bajgain, A., Ali, A., & Mohammed, L. (2022). Urinary tract infection induced delirium in elderly patients: A systematic review. Cureus, 14(12), 1–11. https://doi.org/10.7759/cureus.32321
Kranz, J., Schmidt, S., Wagenlehner, F., & Schneidewind, L. (2020). Catheter-associated urinary tract infections in adult patients—preventive strategies and treatment options. Deutsches Aerzteblatt Online, 117(6). https://doi.org/10.3238/arztebl.2020.0083
Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(158), 1–10. https://doi.org/10.1186/s12912-021-00684-2
Nakhleh, A., & Shehadeh, N. (2021). Hypoglycemia in diabetes: An update on pathophysiology, treatment, and prevention. World Journal of Diabetes, 12(12), 2036–2049. https://doi.org/10.4239/wjd.v12.i12.2036
Tran, L. N., & Puckett, Y. (2020). Urinary incontinence. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559095/
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Question 
Module 01 Content
Purpose
To use critical thinking and data collection to recognize and report complications that may impact the morbidity and mortality of clients experiencing alterations of the urinary system.
Course Competency
Select appropriate nursing interventions for clients with disorders of the urinary system.
Instructions
You are an LPN working on a medical-surgical floor in a team that consists of an RN and a medical assistant. Read through some of the chart entries over 48 hours and answer the questions at the end. Please make sure you cite any sources using APA format. You will find when there is a major clue.
Case Study – Complications Associated with the Urinary System
0130: Admission nurse’s note (RN): The client arrived via EMS from long-term care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. The finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt is now alert and oriented X 4. A report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence.
600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. was admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor: