Running head: DISCHARGE PLANNING PROJECT

Discharge Planning Project

Alexandra Bair
University of South Florida

Discharge Planning Project

The patient is a 31-year-old female who presented to the emergency department on
Tuesday, October 13, 2015 complaining of right flank pain and a fever of 105 degrees
Fahrenheit. The fever had started on Thursday, October 8, 2015, five days prior to the patient
seeking treatment. Accompanying the fever, the patient had other symptoms of nausea and
vomiting. The patient hydrated with fluids and rest trying to allow the fever and illness to pass.
At Bayfront ED, the patient noted having hematuria and dysuria. The duration of the right flank
pain is constant with sharp, throbbing and shooting pains that radiate to the right upper abdomen.
The patient was found to have an oral temperature of 105.9 degrees Fahrenheit and a heart rate of
118 beats per minute and was in sinus tachycardia in the emergency room. The patients blood
pressure was 113 systolic and 54 diastolic. The patient was taken to computerized tomography
(CT) which revealed acute pyelonephritis. The patients lactic acid level was greater than 4. She
was aggressively fluid resuscitated through intravenous (IV) fluids and pain control with
significant improvement. The patient received IV antibiotic Rocephin and was admitted to a
medical floor for continued evaluation and care. The patients fever was relieved and a
temperature within normal limits. Blood cultures and urine cultures were taken. Nothing grew
from the blood cultures and Escherchia coli (E. coli) was grown from the urine culture. The
patient received 2 grams IV Rocephin daily and also received continuous IV fluids. As of
October 15, 2015, the patient was doing well and was ready to be discharged home.

Discharge Diagnosis
The patient is aware that she was hospitalized because she had acute pyelonephritis due
to E. coli. The most likely cause was an untreated urinary tract infection caused by E. coli which
ascended up the urethra into the bladder, up the ureters and into the kidneys (Osborn, Wraa,
Watson, & Holleran, 2014). The flank pain and hematuria was caused by the inflammatory
process fighting the bacteria which allowed red blood cells (RBCs) to infiltrate into the urine.
The inflammatory process also caused the fever and chills. The patient understands the severity
of the infection and the need to seek medical treatment promptly upon developing the symptoms
of fever higher than 102 degrees Fahrenheit for longer than 2 days, accompanied by dysuria,
hematuria, and flank pain (Osborn et al., 2014).
It was explained to the patient that pyelonephritis is a focal and irregular inflammatory
process related to an infection in the kidneys that affects the tissue, tubules, calyces, medulla, and
renal pelvis (Huether & McCance, 2012). The infection is most commonly caused by bacteria
such as E. coli, Proteus, and Pseudomonas. Signs and symptoms of pyelonephritis include
urinary urgency, frequency, burning dysuria, hematuria, fevers, chills, flank pain and fatigue. It
is diagnosed through urinalysis, urine culture, KUB which is an X-ray of the kidneys, ureters and
bladder, and CT scan, along with signs attained though a clinical assessment (Osborn et al.,
2014). Risk factors for pyelonephritis include being a female because the shorter urethera and
proximity to the anus (Huether & McCance, 2012). Not only is being a female a risk factor but
being a sexually active female or pregnant puts the patient at higher risk. Other risk factors
include bacteria introduced by instrumentation like catheterization, inability to empty ones
bladder through urinary obstruction or urinary stasis. If the infection is left untreated, the patient
can develop renal failure, severe sepsis, or septic shock, can require admission to intensive care
units or even cause death. Treatment for pyelonephritis caused by E. coli includes antibiotics
such as sulfa drugs, cephalosporins, amoxicillin, and fluoroquinolones. The patient should
increase fluid intake to flush the body of the infection (Osborn et al., 2014).
The patient was advised to take antibiotic regimen to completion as prescribed in order to
make sure the infectious agents were eliminated. The patient must take the antibiotics for 14
days. The patient was also directed to make a follow-up appointment with their primary care
provider within a week after discharge from the hospital to make sure treatment is working and
symptoms do not recur. The patient was told to notify her physician if she develops a
temperature greater than 101 degrees Fahrenheit, a rapid heart rate, chills, sweats, dizziness,
confusion, and nausea or vomiting.
There were no associated core measures. The Adult Sepsis Screening tool was used in
evaluating this patient. The criteria for suspected sepsis includes leukopenia or a low white
blood count (WBC) of 2.6, a high fever of 105.9 degrees Fahrenheit, and tachycardia with a heart
rate of 118 beats per minute. From that criteria, two blood cultures were drawn from two
separate sites, a urinalysis and culture was done, the serum lactate level was obtained, a broad
spectrum antibiotic and IV fluid therapy was initiated as per sepsis protocol.
Medications for Discharge
A reconciled list of new and discontinued medications was provided to the patient upon
discharge. This list included information including the type of medication, dosage, route, last

DISCHARGE PLANNING PROJECT

dose time the medication was taken and when the next expected dose should be taken. The
patient was also provided with the prescriptions for new medications. Education regarding the
medications was discussed with the patient prior to discharge. The patient showed an
understanding of the different types of medications and the reasons for taking them. The side
effects were also discussed with understanding from the patient. The patient will resume taking
her normal medications of buspirone (Buspar) 10 mg daily, quetiapine (Seroquel) 200 mg at
bedtime, risperidone (Risperdal) 2 mg at bedtime, and sertraline (Zoloft) 50 mg daily. The new
medications the patient was prescribed are the antibiotic ciprofloxacin hydrochloride (Cipro) 500
mg twice a day for 14 days and the urinary analgesic phenazopyridine hydrochloride (Pyridium)
500 mg three times a day for two days after meals for urinary urgency and frequency. The
patient was explained the two new medications and received the following patient teachings:
Ciprofloxacin (Cipro) 500 mg oral tablet, twice daily anti-infective, pharmaceutical
class fluoroquinolones. Indication: treatment of urinary tract infections including cystitis and
pyelonephritis. Side effects can include elevated intracranial pressure, seizures, agitation,
confusion, depression, dizziness, drowsiness, hallucinations, headache, insomnia, nightmares,
paranoia, tremor, hepatotoxicity, pseudomembranous colits, abdominal pain, diarrhea, nausea,
vaginitis, photosensitivity, rash, hyper- or hypoglycemia, eosinophilia, tendinitis, tendon rupture,
peripheral neuropathy, and anaphylaxis.
Patient is taught to take medication as directed at evenly spaced times and on an empty
stomach 1 hour before or 2 hours after meals with a full glass of water. Patient is taught to finish
drug completely, even if feeling better. Patient will take missed doses as soon as possible unless
almost time for next dose and not to double dose. The patient is encourage to maintain fluid
intake of at least 1,500-2,000 mL per day to prevent crystalluria. Patient is advised that antacids
or medications containing calcium, magnesium, aluminum, iron, or zinc will decrease absorption
and should not be taken within 4 hours before and 2 hours after taking this medication. This
medication may cause dizziness and drowsiness so the patient is cautioned to avoid driving or
other activities requiring alertness until response to medication is known. The patient is advised
to use sunscreen while taking this medication to prevent phototoxicity reactions during and for 5
days after therapy. The patient will notify health care professionals if a sunburn-like reaction or
skin eruption occurs. Patient is advised to notify health care professional of all medications
including prescription, over the counter medications, vitamins, or herbal products being taken.
Patient is taught signs of superinfection (furry overgrowth on tongue, vaginal itching or
discharge, loose or foul-smelling stools) and to report them to a health care professional. Patient
is instructed to notify health care professional if fever and diarrhea develop and not to treat
without consulting the health care provider. The patient is instructed to notify the health care
professional immediately if signs and symptoms of hepatotoxicity (anorexia, jaundice, dark
urine, pruritus, or tender abdomen), rash, signs of hypersensitivity, or tendon pain, swelling or
inflammation occur. If tendon symptoms occur, patient will avoid exercise and use of the
affected area.
Phenazopyridine (Pyridium) 500 mg oral tablet, three times a day for two days after
meals urinary tract analgesics. Indication: provides relief from pain, itching, burning, urgency,
and frequency which may occur in associate with infection. Side effects include headache,
vertigo, hepatotoxicity, nausea, bright-orange urine, renal failure, rash, hemolytic anemia, and
methemoglobinemia.

DISCHARGE PLANNING PROJECT

Patient is instructed to take medication exactly as directed, with taking a missed dose as
soon as remembered unless almost time for next dose. The patient is advised that while
phenazopyridine administration is stopped once pain or discomfort is relieved, concurrent
antibiotic therapy must be continued for full duration of therapy. The patient is informed that the
drug causes reddish-orange discoloration of urine that may stain clothing or bedding. This may
also cause staining of soft contact lenses, so patient should not wear contacts while taking this
medication. The patient is instructed to notify health care professional if rash, skin discoloration,
or unusual tiredness occur.
Home Assessment
Patient lives in a one story halfway house in St. Petersburg named My Place of
Recovery. The patient currently lives with fifteen other people in the same household. The
patient has no mobility limitations at time of discharge. The patient is in a safe and stable living
situation. The patient uses public transportation. Her boyfriend also drives her to pick up
medications and will drive her to her follow up appointments. The patient has Medicare
coverage and does not express any concern about being able to pay for medications or her
follow-up appointments.
Follow Up
The patient has no need for home health services or durable medical equipment at home.
The patient has no need for social work, physical therapy or occupational therapy to be included
in the discharge planning. The patient has been advised to follow up with her primary care
provider in one week to ensure the proper recovery process. The patient declined to have the
hospital set up this appointment because the patient is unsure of her boyfriends schedule and he
will be driving her to the appointment. The patient was advised to schedule the appointment as
soon as possible to make sure she is able to get an appointment. Patient does not need to follow
up with a specialist but could follow up with the hospital urologist if she felt so inclined.
Summary
The most common reasons that patients with pyelonephritis are readmitted is because of
lack of compliance with antibiotic drug therapy. The patient does not take antibiotics to
completion, allowing some bacteria to remain alive and a recurrent infection occurs (Osborn et
al., 2014). Antibiotic resistance in uropathogenic bacteria has been increasing in large part due
to antibiotic overuse and lack of compliance to finish drug therapy. A follow-up urine culture
will be obtained after treatment if symptoms recur (Huether & McCance, 2012). The best way to
ensure the patient will not be readmitted is prevention education. Female patients should be
instructed to wipe from front to back and to void before and after sexual intercourse to flush the
bladder and urethera. The use of absorbent, cotton underwear increases risks for urinary tract
infections and female patients should pay special attention to hygiene during menses (Osborn et
al., 2014). Educating the patient on signs and symptoms of infection and when to seek treatment
is also a way to prevent the infection from progressing and getting worse.

DISCHARGE PLANNING PROJECT

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References

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis,
MO: Mosby, Inc.
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-Surgical Nursing:
Preparation for Practice (2nd ed., pp 1417-1464). Upper Saddle River, NJ: Pearson
Education, Inc.