Millie Larsen Part 1

Scenario Overview

Patient: Millie Larsen

Diagnosis: Urinary tract infection

This scenario is part of the Millie Larsen Unfolding Case. The scenario can be used as a standalone scenario or as part 1 of the case.

The Unfolding Case

Millie Larsen is an 84-year-old Caucasian female who lives alone in a small home. Her husband Harold passed away a year ago and she has a cat, Snuggles, who is very important to her. Millie has one daughter, Dina Olsen, who is 50 years old, lives nearby, and is Millie’s major support system. Millie’s current medical problems include hypertension, glaucoma, osteoarthritis of the knee, stress incontinence, osteoporosis, and hypercholesterolemia.

The scenarios take place over 3 days when Millie is in the hospital with a diagnosis of urinary tract infection and dehydration. Her presentation is atypical, and she is confused. The scenarios depict varied situations Millie encounters during her brief hospital stay. The objectives focus on assessment; appropriate use of assessment tools such as the SPICES: An Overall Assessment Tool for Older Adults, a fall risk assessment tool, and Confusion Assessment Method (CAM); communication skills; conflict between Millie and her daughter on living arrangements; functional assessment; discharge teaching; and making appropriate referrals.

Brief Summary of Present Scenario

The scenario is set at 7 p.m., and Millie is in the emergency department. She was brought in with confusion by her daughter Dina three hours ago. As the scenario unfolds, it will become clear that due to her confusion, Millie has not been taking her medications properly in the days prior to admission and, as a result, her blood pressure is very elevated. Millie’s daughter Dina is at the bedside and is quite concerned about the confusion and elevated blood pressure. The students receive a report from the emergency room triage nurse and are expected to perform a general assessment as well as use the Confusion Assessment Method (CAM) and Morse Fall Scale tools. Objectives for this scenario include the identification and use of appropriate assessment tools for older adults, recognition of an elevated blood pressure, and notification of the physician, using SBAR format.

Learning Objectives

Upon completion of the scenario, the student should be able to:

· Perform a head-to-toe physical assessment and focused assessment of the patient’s mental status

· Assess the patient’s individual aging pattern and functional status using standardized assessment tools, including:

· Confusion Assessment Method (CAM)

· Morse Fall Scale

· Identify critical assessment findings, including elevated blood pressure and confusion

· Identify the need to communicate with other members of the health care team using SBAR format

· Report pertinent assessment findings and relate which findings are commonly found in the older adult patient

· Recognize geriatric syndrome(s) present in simulation, including:

· Urinary incontinence

· Confusion

Patient Case Introduction to Students

Time: 1900

Report from emergency room triage nurse:

Millie Larsen is an 84-year-old female who lives alone in a small home. She arrived with her daughter, Dina, three hours ago. Her daughter noticed that Millie wasn’t making sense or acting normally during a visit earlier today. She was seen by Dr. Lund an hour ago. He suspects urinary tract infection and has written preliminary orders. An IV has been started and labs have been drawn. They just came back. I haven’t had a chance to look at them. Her antibiotic also just arrived from the pharmacy and needs to be given. I completed a SPICES assessment, which indicated problems with incontinence and confusion. The result is in the health record. The confusion needs to be further assessed, and her fall risk should also be assessed. Can you please do that?

Patient Details

Patient Data: female- Age: 84 years. Weight: 68 kg (150 lbs). Height: 155 cm (61 in).

Allergies: No known

Past Medical History: Glaucoma, hypertension, osteoarthritis, stress incontinence, hypercholesterolemia.

History of Present Illness: Millie’s daughter became concerned when she stopped over to check on her and found her still in her bathrobe at 3 p.m. The house was very unkempt, and Millie couldn’t remember her daughter’s name.

Social History: Not recorded.

Primary Medical Diagnosis: Dehydration, suspected urinary tract infection.

Surgeries/Procedures & Dates: Cholecystectomy at age 30.

Provider’s Orders

· Bedrest, bathroom privileges with assistance

· Regular, low fat diet

· Vital signs and SpO2 every 2 hours

· I & O

· Notify physician if systolic BP > 150 or < 100; temperature > 38°C, Urine output < 60 mL in 2 hours

· Ciprofloxacin 400 mg IV every 12 hours for 24 hours, then Ciprofloxacin 500 mg PO every 12 hours for 10 days.

· Acetaminophen 650 mg PO every 4–6 hours as needed

· IV fluids D5 0.45 NaCl + 20 mEq KCl at 60 mL/hr

· CBC with diff., BMP, urine analysis, urine culture

Nursing Diagnoses

· Risk for Falls related to age > 65 years, diminished mental status, and antihypertensive medications

· Impaired urinary elimination related to degenerative changes in pelvic muscles and urinary tract infection

· Risk for Imbalanced Fluid Volume related to decreased oral intake of fluids, possible misuse of diuretic medications and IV fluid administration

· Acute Confusion related to fluid volume deficit and urinary tract infection

Overview of Proposed Correct Treatment

· Wash hands

· Introduce self

· Identify patient

· Obtain vital signs

· Identify elevated blood pressure

· Auscultate heart and lungs

· Assess pain

· Assess IV site, fluid and rate

· Evaluate lab data

· Identify abnormal urine analysis and electrolytes

· Begin assessments:

· Head-to-toe

· CAM assessment

· Fall risk assessment

· Focus on communication with Dina to gain necessary information for the CAM

· Educate Dina about relationship between UTI and delirium

· Identify geriatric syndromes, including confusion and incontinence

· Consider safety precautions

· Call provider and give report using SBAR

· Assess ability to take oral medications

· Administer medications

Case Considerations

Millie exhibits an atypical presentation (delirium) for a urinary tract infection that is common in the older adult population. In addition, she has other coexisting chronic conditions, including hypertension, and due to her confusion she has not been taking her medications correctly. As a result her blood pressure is highly elevated.

It is important that the nurse understands the research underlying the concept of atypical or unique presentations in older adults, how they may differ from the general adult population, and the complexity of care required by several coexisting conditions.

The focus of the assessment in this scenario is on evaluating Millie’s current condition, including assessing her confusion. Using standardized evidence-based tools for the assessments allows for a systematic approach to the patient. In this case the Confusion Assessment Method (CAM) will help to quickly and precisely identify the presence of delirium. To ensure safety, Millie’s risk of falling also needs to be assessed. Although she is living independently under normal circumstances, the acute change in her status can greatly increase her risk of falling.

The nurse should also recognize other abnormalities, including the highly elevated blood pressure and abnormal lab findings to include the urine analysis, and communicate the findings clearly and promptly to the provider. The use of the standardized SBAR format will assist with communication of clinically relevant information.

During assessments the nurse should communicate therapeutically with the daughter, Dina, as the primary source of information. It is important to focus attention on the differences between Millie’s presentation at the hospital and her normal baseline. The nurse should explain the relationship between urinary tract infection and delirium to Dina. Under normal circumstances, Millie is well-functioning, and seeing her so confused can be an upsetting experience.

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