NUR 616 Module 8 SOAP Note Example

SOAP Note: Asymptomatic Bacteriuria in an 86-Year-Old Nursing Home Resident With Dementia

[Student Name]

Southern New Hampshire University

NUR 616: Primary Care of Adults and Gerontological Patients

Module Eight SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Asymptomatic Bacteriuria in an 86-Year-Old Nursing Home Resident With Dementia

Bacteria live in the bladders of many older women without causing harm; in nursing homes, between a quarter and a half of women have a positive urine culture at any time. When a resident seems tired or confused, staff often send a urine sample, the culture is positive and an antibiotic follows. The result is a large share of all antibiotic use in long-term care, with side effects, Clostridioides difficile infection and resistant organisms as the cost. This SOAP note documents a resident with a positive culture and argues that, because she lacks urinary symptoms and systemic signs, the correct plan is not to treat and to find the true cause of her change.

Subjective

Reason for visit: nursing home review requested by the charge nurse for a positive urine culture.

History of present illness: Mrs. D. is an 86-year-old resident with moderate Alzheimer dementia who has lived in the facility for three years. Two days ago the nursing assistant noticed that her urine in the incontinence brief looked cloudy and smelled strong, and staff felt she had been sleepier than usual for about three days, dozing through two afternoon activities. A urine sample was sent. Staff report no fever, no new or worsening incontinence beyond her baseline, no visible blood in the urine and no signs of pain when she urinates or when her abdomen is touched. She is eating about half her usual meals and drinking less than usual since the facility's heating was turned up. There has been no fall, cough, vomiting or diarrhea. She cannot reliably report symptoms but denies pain when asked.

Medications: donepezil 10 mg, amlodipine 5 mg, acetaminophen 650 mg as needed and, since four days ago, trazodone 50 mg at bedtime, added by the covering clinician for poor sleep. Allergies: penicillin. Baseline: needs help with bathing and dressing, feeds herself, walks with a walker, incontinent of urine at baseline, recognizes her daughter.

Objective

Vital signs: temperature 36.9 degrees Celsius (baseline 36.6 to 37.0), blood pressure 118/64 mm Hg lying and 104/60 standing with lightheadedness, pulse 84 lying and 98 standing, respiratory rate 16, oxygen saturation 96% on room air.

Examination: drowsy but rousable to voice, follows simple commands, oriented to person only, which is her baseline; attention on reciting months backward is similar to her documented baseline. Mucous membranes dry. Lungs clear. Heart regular, no murmur. Abdomen soft, no suprapubic tenderness, no bladder distension on palpation. No costovertebral angle tenderness. Skin intact, no pressure injuries. No focal neurologic signs.

Laboratory results: urinalysis with positive leukocyte esterase, 10 to 20 white cells per high-power field, positive nitrite. Urine culture: Escherichia coli at a count above 100,000 organisms per mL, sensitive to nitrofurantoin. Basic metabolic panel today: sodium 146 mmol/L, BUN 32 mg/dL, creatinine 1.3 mg/dL (baseline 0.9).

Assessment

1. Asymptomatic bacteriuria with pyuria. She has no fever, no new urinary symptoms, no suprapubic or flank tenderness and no signs of sepsis. The Loeb minimum criteria for starting antibiotics in a resident without a catheter require acute dysuria alone or a fever paired with something new in the urinary tract, whether urgency, frequency, pain over the bladder, visible blood, flank tenderness or fresh incontinence; in a cluster randomized trial, using these criteria reduced antibiotic courses for suspected urinary infection in nursing homes (Loeb et al., 2005). She meets none. Her daughter confirmed that the incontinence pattern is unchanged from last month's care conference notes. Pyuria and a positive nitrite do not distinguish infection from colonization in this population, and cloudy, malodorous urine is not a sign of infection.

2. Mild dehydration with prerenal acute kidney injury, supported by reduced intake, dry membranes, orthostatic changes, a raised sodium and a creatinine rise from 0.9 to 1.3.

3. Increased sleepiness, most likely from dehydration and the new trazodone, which can cause sedation and orthostatic hypotension. There are no signs of delirium beyond her baseline on attention testing. The 2019 IDSA guideline recommends that older adults with functional or cognitive impairment who have bacteriuria and a change in mental status, but no local urinary symptoms or systemic signs of infection, be assessed for other causes and observed rather than treated with antibiotics (Nicolle et al., 2019).

Plan

No antibiotics for the bacteriuria. Hydration: encourage 250 mL of fluid every two hours while awake, offer preferred drinks, and lower the room temperature; recheck the basic metabolic panel in 48 hours. Medications: stop trazodone; address sleep with a regular daytime activity schedule, daylight exposure and a consistent bedtime routine. Hold amlodipine while orthostatic and recheck blood pressure daily. Observation: staff will record temperature and a brief attention check each shift for 72 hours and call for a temperature of 37.8 degrees Celsius or above or 1.5 degrees above baseline, new pain on urination, visible blood, flank pain, vomiting, falling blood pressure or a clear change in alertness from today. Urine cultures should not be sent unless those criteria are met. The daughter was called and agreed with the plan. The medical director was informed, since the facility tracks antibiotic starts and urine cultures as part of its stewardship program, and this case will be reviewed at the next monthly infection control meeting as an example of the assessment tool in use.

Staff Education

The charge nurse and nursing assistants were thanked for noticing the change and were reminded that cloudy or foul-smelling urine is not a reason to send a culture, that most older women in the facility would have a positive culture if tested and that a change in alertness should prompt checks of fluids, medications, vital signs and bowel habits first. A copy of the facility's urinary infection assessment tool based on the Loeb criteria was placed at the nursing station. Studies of long-term care report that uncertainty about symptoms in residents with dementia drives much of this testing, and simple structured tools reduce it (Nace et al., 2014).

Conclusion

Mrs. D.'s positive culture reflects colonization, not infection. By documenting the absence of urinary and systemic signs, applying explicit criteria and finding dehydration and a new sedating drug, the note avoids an antibiotic she does not need and treats the problems that are actually making her tired.

References

Loeb, M., Brazil, K., Lohfeld, L., McGeer, A., Simor, A., Stevenson, K., Zoutman, D., Smith, S., Liu, X., & Walter, S. D. (2005). Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. BMJ, 331(7518), 669-672. https://doi.org/10.1136/bmj.38602.586343.55

Nace, D. A., Drinka, P. J., & Crnich, C. J. (2014). Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. Journal of the American Medical Directors Association, 15(2), 133-139. https://doi.org/10.1016/j.jamda.2013.11.009

Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Koves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110. https://doi.org/10.1093/cid/ciy1121