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 were given, and repeat finger stick 104 was given. The is now alert and oriented X 4

Complications Associated with the Urinary System

Q1.

The patient was reported to be confused and combative upon review by the RN at 0100. The most likely cause of confusion and combativeness in the patients is the development of a urinary system infection. Mayne et al.(2019) report that sudden and unexplained confusion among patients with diabetes may be suggestive of an infection. The patient in the case is a known diabetic. The events preceding her presentation, such as catheterization, may have predisposed her to a urinary tract infection. Additionally, the presence of cloudy yellowish urine is also suggestive of a urinary tract infection.

Q2. 

A likely error made in the ER that may have precipitated the patient’s presentation is catheterization. Urethral catheterization is responsible for over 80% of all nosocomial urinary tract infections. The patient in the case, having undergone catheterization for the management of urinary incontinence, was at high risk for developing a urinary tract infection.

Q3.

The patient in the case is likely to have experienced urinary overflow incontinence. Overflow urinary incontinence occurs due to inefficient bladder emptying. This leads to urinary leakage. This problem is prominent among diabetics. Nazzal et al. (2019) postulate the links between diabetes disease processes and urinary incontinence. Urinary leakage in this regard may result from a neurogenic bladder caused by diabetic neuropathy. Overflow urinary incontinence is also common among females. Flores-Mireles et al. (2019) report that women are up to twofold more likely to develop incontinence than their male counterparts. Additionally, concurrent urinary tract infection in diabetic women increases their likelihood of experiencing urinary leakage. The patient in the case provided was a known diabetic female. Her chances of developing urinary incontinence were thus higher.

Q4.

Several factors in the patient’s history may have contributed to her disease and symptom exacerbation. The patient’s history of smoking may have been a contributing factor to her infection. Jiang et al. (2020) reveal the correlation between long-term smoking and risk for infectious illnesses among diabetic patients under long-term management of their disease. Host susceptibility to developing infections among persons with significant histories of smoking is thought to be a result of alterations in the structural and functional immune cell defences. Rheumatoid arthritis is another factor in the patient’s history that may have contributed to her infection. Rheumatoid arthritis can impair immune functionalities and therefore, predispose an individual to infections. The development of an infection in the patient’s case may result from a long-standing immune decline. The presence of these two factors may have interplayed in the symptom exacerbation seen in the patient.

Q5.

RN-physician communication lapses may have contributed to the poor outcomes of the patients. There seems to be a one-hour lapse between the detection of the patient’s deteriorating state, as documented by the LPN, and the RN’s rapid response call. As documented by the LPN, the catheter was draining cloudy urine, the patient appeared abnormally confused, and her daughter noted that she was very warm. All these were indicative of the patient’s deteriorating state of health and would have promoted an emergency call. However, this was not the case, as the RN waited another hour before calling the emergency response services.

References

Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, treatment, and prevention of catheter-associated urinary tract infection. Topics in Spinal Cord Injury Rehabilitation, 25(3), 228–240. https://doi.org/10.1310/sci2503-228

Jiang, C., Chen, Q., & Xie, M. (2020). Smoking increases the risk of infectious diseases: A narrative review. Tobacco Induced Diseases, 18(July). https://doi.org/10.18332/tid/123845

Mayne, S., Bowden, A., Sundvall, P.-D., & Gunnarsson, R. (2019). The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing – a systematic literature review. BMC Geriatrics, 19(1). https://doi.org/10.1186/s12877-019-1049-7

Nazzal, Z., Khatib, B., Al-Quqa, B., Abu-Taha, L., & Jaradat, A. (2019). The prevalence and risk factors of urinary incontinence amongst Palestinian women with type 2 diabetes mellitus: A cross-sectional study. Arab Journal of Urology, 18(1), 34–40. https://doi.org/10.