Question

At the start of the shift, you are assessing an 86 year old patient who is awaiting surgery for a hip repair after a fall 12 hours ago at home. You are collecting a clean-catch urine specimen, using a bedpan, as part of the preoperative preparation. You observe that when she voids, the urine odor is foul and the urine is cloudy and full of sediment. She reports some urgency but notes that she had urgency before her fall.

What assessment information will you document in the chart?

What additional information should you ask the patient and what else should you consider?

Organize your thoughts into a SBAR communication.

Who should you notify and why?

Answer 1

The following information has to be documented after the assessment

• Color of the urine (cloudy with sediments )
• odour of the urine (foul smelling )
• Urgency of urine present  

This all is a sign of urinary tact infection

The additional information to be asked are

• How long she is having this complaint
• Does she pass urine frequently, or in minimal quantity
• Presence of pain ,irritation while voiding ,pelvi of lower abdominal pain

These helps to diagnose the patient earlier and provide necessary treatment or intervention

It shoudd be notified to the concerned provider

Situation

This is nurse... from ...regarding 86y/F patient with fractured hip posted for hip repair.

Background

As a part of routine preoperative investigation, a urine routine has been collected.The patient is complaining of urgency while voiding and is experiencing it right before admission.I am concerned because the urine is cloudy with sediments and fouls smelling

Assessment:

It seems to be the patiwnt patient is having an urinary tract infection

Recommendation:

Please suggest the necessary treatment,should I start with any antibiotic.