Mrs. Phillips is an 84 year old female who arrived to the Emergency Department from a nursing home, where caregivers report she has altered mental status, confusion, and weakness that they just noticed this morning. The nurse inserts 2 large bore PIV’s and draws blood for a chemistry and complete blood count, as ordered by the Provider, who is concerned she may be having a stroke.

Mrs. Phillips’s vitals are as follows:

HR 122 RR 24

BP 92/58 SpO2 92%

Temp 103.6°F

Her NIHSS score is 2, CT scan is negative for an intracranial bleed, and the neurologist believes she is NOT having a stroke.  The nurse is called into the room by the caregivers as the patient has wet herself. The nurse notes a foul, sour odor to the urine. Mrs. Phillips’ blood pressure is now 88/52. The nurse notifies the Provider.

The provider places orders for the following:

Keep SpO2 > 92%

Blood Cultures x 2

Urinalysis

Urine Culture

500 mL NS IV bolus STAT

100 mL/hr NS IV continuous infusion

Vancomycin 1,000 mg IV x 1 dose NOW.

The nurse obtains 2 sets of blood cultures and the UAP obtains a sterile urine sample via I&O cath. The UAP reports cloudy, foul-smelling urine.  The nurse initiates the IV fluid bolus and requests the Vancomycin from the Pharmacy. Mrs. Phillips’ caregiver asks why she is so confused?

After 3 days of treatment with IV antibiotics, Mrs. Phillips is awake and oriented x 2-3 (she has dementia at baseline and occasionally thinks it’s 1946). She is calm, conversing with staff, and able to ambulate the halls. She will be discharged home with PO antibiotics tomorrow.