Training Module 4 Case Scenario: Mr. Jones

How to Avoid the Harms of Antibiotic Overuse

Directions:

Divide into small groups of two to three people.
Groupsshould work through each part of the case scenario, pausing for discussion before moving to the next section.

Part 1

Mr. Jones is an 83-year-old man who has dementia and an indwelling urinary catheter. During the morning assessment, the nursing assistant notices that Mr. Jones is less active than normal. The dietary staff later notices that Mr. Jones is eating less. During the evening assessment, the nursing assistant notices that his urine output is reduced and that it has a strong odor. The nursing assistant tells the nurse on duty who reviews his chart, but does not see any notes on changes in condition. She chooses to observe Mr. Jones and check in with other staff on how Mr. Jones was earlier in the day.

The next morning, Mr. Jones’ daughter comes to visit him and tells the nurse that he didn’t seem like himself, that he seemed confused and that his urine looked cloudy and had an odor when the nursing assistant was emptying his drainage bag. She’s concerned that he has a urinary tract infection and asks for him to get started on antibiotics.

How should the nurse respond to Mr. Jones’ daughter’s request for him to be started on antibiotics? Develop a SBAR to respond to the daughter’s concerns.

FACILITATOR NOTES:

Have an example SBAR prepared to guide the conversation with staff members. Remember the SBAR mnemonic.

First, explain the Situation. What is the current state of the resident and the issue Mr. Jones’ daughter is concerned about?
Next, share some Background information about Mr. Jones and why it can be unsafe for him to receive unnecessary antibiotics.
Provide Mr. Jones’ daughter with your Assessment of the situation; what other factors might be influencing his health and what makes you think that this might not be a CAUTI?
Finally, share your alternative Recommendation for Mr. Jones’ care. It is helpful to emphasize that you are recommending this course of action out of your concern for Mr. Jones’ safety.

Part 2

Two days after, staff and Mr. Jones’ daughter note changes in his behavior. The activities coordinator informs the nurse that Mr. Jones began sweating and complained of being hot. The nurse says, “Okay, I’ve been feeling hot today too. I’ll check on him later.” The activities coordinator feels like this is a more serious issue.

How should the activities coordinator respond to this situation? Develop a CUS for the activities coordinator to communicate her concerns about Mr. Jones with the nurse.

FACILITATOR NOTES:

Have an example CUS prepared to guide the conversation with staff members. Remember the CUS mnemonic.

First, explain what the activities coordinator is Concerned about (i.e., I am concerned...).
Then explain why the activities coordinator is concerned (i.e., I am Uncomfortable…).
State why this is a Safety issue.

Part 3

The nurse realizes the potential severity of the situation after the activities coordinator explains her concerns. She immediately contacts the attending physician, explains the signs and symptoms Mr. Jones has developed in the past two days and requests antibiotics.

Should the attending physician prescribe antibiotics for Mr. Jones? Explain why or why not.

ANSWER: NO

Explanation: Mr. Jones exhibited signs of rigors and new onset confusion, but we don’t know if there is another condition that could explain his symptoms. Cloudy, smelly urine does not meet the CAUTI criteria. There has not been a urinalysis conducted to determine if this is in fact a CAUTI; further diagnostic tests are needed to confirm a CAUTI and prescribe antibiotics.