Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of
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Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance.
Personal/Social History:
Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are active and involved in her life.
What data from the histories are important and RELEVANT and have clinical significance for the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Progressively worsening fatigue, fever, and painful, burning, and frequent urination.
Sudden onset of confusion (change in mental status) with no prior history Clinically significant symptoms of urinary tract infection prompting request for an order for a urinalysis.
Confusion is a common presentation of UTI in the elderly, and change in mental status from baseline should always be fully investigated.
RELEVANT Data from Social History: Clinical Significance:
Lives in a senior retirement community with daughters who are actively involved in her life and wears a life alert button Jean has a strong support system and a safe place to return to after discharge that will provide support. Her life alert button provides the security she needs in the event of an emergency since she lives alone.
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