Problem
Mrs. Smith is a 78-year-old female who arrives to the emergency department from a nursing home. The nursing home nurse report she has increased confusion, altered mental status, and weakness that was noticed this morning. The emergency department nurse inserts 2 large bore IV's and draws blood for a complete blood count and chemistry orders by the provider, who is concerned she may be having a stroke.
Mrs. Smith's vitals are as follows: HR 122 RR 24BP 92/58 SpO2 92%Temp 103.6°FHer stroke score is normal, CT scan is negative for an intracranial bleed, and the neurologist doesn't think she is having a stroke. The nurse returns to the Mrs. Smith's room and finds that she had wet herself. The nurse notes a foul odor to the urine. Mrs. Smith's blood pressure is now 88/52. The nurse notifies the provider.
1. What orders do you anticipate from the provider?
2. What may be going on with Mrs. Smith physiologically?
The provider places orders for the following:
Keep SpO2 > 92%
Blood Cultures x 2
Urinalysis
Urine Culture
500 mL NS IV bolus STAT
100 mL/hr. NS IV continuous infusion
Vancomycin 1,000 mg IV x 1 dose
3. Which order should be implemented first? Why?
4. Why is Mrs. Smith presenting with Altered Mental Status?
After 3 days of treatment with IV antibiotics, Mrs. Smith is awake and oriented x 2-3 (she has dementia at baseline and sometimes thinks it's 1957). She is calm, talking with staff, and able to ambulate the halls. She will be discharged home with oral antibiotics tomorrow.
5. What discharge teaching should be provided to Mrs. Smith and the caregivers at her nursing?