Scenario Summary The Joint Commission has recently visited Little Falls

An 87-year-old client was admitted to the hospital three weeks ago with a urinary tract infection, dehydration, and potential sepsis. After a hospital stay of 4 days, the client was discharged to an independent living facility with the support of home health care. Today the client’s child takes them for a follow- up visit to the physician. The office nurse assesses the client prior to the physician’s examination and compares the client findings with the ED assessment below. Health History Nurses’ Notes Physician’s Orders Lots Tens 1420: 87-year-old client admitted to the ED from independent living apartment with new report of episodic acute confusion, urinary frequency and incontinence, and severe fatigue. Son states that client is independent in ADLs and has no history of dementia. Client was admitted last month to the hospital for 3 days after a mild stroke, but had no residual symptoms. Has had type 2 diabetes mellitus for about 15 years. Admission vital signs: T 100.8 F (38.2.C), HR 96 BPM, RR 20 bpm, BP 98/46, Spo2 90% on RA. Alert and oriented x 1 (person). Lungs clear, S1 and $2 present with no murmurs or gallops. Extremities cool with capillary refill greater than 5 seconds. Both legs slightly mottled with 1+ edema. 1450: Urinalysis shows numerous WBCs, casts, and few CBCs. Cath urine specimen for culture and sensitivity sent to laboratory. Peripheral IV of 5%D/NS started in left forearm. O2 2L/min via NC administered. 1530: Normal BMP and CBC results, except for WBCs of 16,000/mm3 (16 x 109/L) with bands greater than 10%. 1715: Discharged to 2 East Medical with diagnosis of urinary tract infection, dehydration, and potential sepsis Select which current assessment findings indicate that the client is improving or not improving. Current Client Finding Improving Not Improving Alert and oriented x 3 Continent of urine without frequency T 97.8 F (36.6.C) HR 82 BPM BP 118/72 mm Hg Spo2 94% Lower extremities (especially feet) cool but no mottling A: Improving: Alert and oriented x 3, Continent of urine without frequency, HR 82 O BPM, Lower extremities (especially feet) cool but no mottling. Not Improving: T 97.8.F (36.6.C), BP 118/72 mm Hg, Sp02 94% B: Improving: Alert and oriented x 3, Continent of urine without frequency, T 97.80F (36.6.C), HR 82 BPM, BP 118/72 mm Hg, Sp02 94%, Not Improving: Lower extremities (especially feet) cool but no mottling. C: Improving: Alert and oriented x 3, Continent of urine without frequency, T 97.8OF (36.6.C), HR 82 BPM, BP 118/72 mm Hg, Not Improving: Sp02 94%, Lower extremities (especially feet) cool but no mottling. D: Improving: Alert and oriented x 3, Continent of urine without frequency, T 97.80F (36.6.C), HR 82 BPM, BP 118/72 mm Hg, Sp02 94%, Lower extremities (especially feet) cool but no mottling. Not Improving: Sp02 94% E: Improving: Alert and oriented x 3, Continent of urine without frequency, T 97.8OF (36.6.C), HR 82 BPM, BP 118/72 mm Hg, Sp02 94%, Lower extremities (especially feet) cool but no mottling. Not Improving: Not Applicable

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