Hôpital régional de Sudbury Regional Hospital

URINARY TRACT INFECTION CARE MAP

INCLUSION CRITERIA:
9 Blood in urine (Hematuria)
9 Difficulty Voiding
9 Dysuria
9 Mild abdominal pain associated with the above symptoms
9 Fever (temperature greater than/equal to 38.0°C)
9 Change in LOC / lethargy

EXCLUSION CRITERIA:
8 Moderate/Severe abdominal pain associated with the above symptoms
8 Hematuria with large clots

TESTS (Medical Directive # EDOS01)

• Urine R&M, C&S
• Bloodwork: CBCD, Electrolytes, Urea, Creatinine, Random Glucose, Calcium
• Blood Cultures X 2 for temperature greater than/equal to 38.0°C
• Baseline & daily INR level if patient on Warfarin (Coumadin) and receiving fluoroquinolone antibiotics

ASSESSMENT
• Vital Signs (temperature, pulse, blood pressure, respiration, oxygen saturation)
• Mental Status including any changes from baseline
• Hydration status (mucous membranes, skin turgor)
• C/O pain, type and location
• Urine colour, consistency,. Foul-smelling urine is NOT to be considered clinically significant in the
differential diagnosis of UTI
• Dysuria
• Caution in patients with immunosuppressed state (HIV, immunosuppressive or antineoplastic drugs,
haematologic malignancy, organ transplant recipient) as potential for increased complications

TREATMENT OPTIONS (Medical Directive # EDOS04)

• Saline lock
Hôpital régional de Sudbury Regional Hospital

MEDICATIONS *******CHECK ALLERGIES & MEDICATION COMPATIBILITY******

(Medical Directive # EDOS03)
FIRST LINE ORAL PARENTERAL
Trimethropin/ 2 tablets BID or 1 DS tablet BID 7 days (max) or until physician r/a
Sulfamethoxazole
Macrobid 100mg BID 7 days (max) or until physician r/a ---

SECOND LINE
Amoxicillin 500mg TID x 7 days (max) or until physician r/a ---
Ciprofloxacin 250mg BID or 500mg daily X 7 days (max) or until physician r/a

THIRD LINE
Levofloxacin 250mg once daily X 7 days (max) or until physician r/a ---

Acetaminophen 375-975mg po (650mg pr) q4hrs prn

ONGOING MEASURES
• Review urine C&S results & adjust medications accordingly
• Nutrition – Regular diet or as ordered. Encourage fluids unless contraindicated. Consider requesting
cranberry juice to alter pH of urine.
• (encourage fluids unless contraindicated)
• Activity as tolerated – if non-ambulatory patient ensure repositioning q2hrs

REFERENCES

Nicolle, L. (2001). The Chronic Indwelling Catheter and Urinary Tract Infection in Long-Term-Care Facility
Residents. Infection Control and Hospital Epidemiology, 22(5), 316-321.

Nicolle, L. (2008). Urinary tract infections in older people. Reviews in Clinical Gerontology, 18, 103-114.

Rosser, W., Pennie, R., Pilla, N., and the Anti-infective Review Panel. (2005). Anti-infective guidelines for
community-acquired infections. Toronto: MUMS Guideline Clearinghouse.

Rueben, D., Herr, K., Pacala, J., Pollock, B., Potter, J., & Semla, T. (2008). Geriatrics At Your Fingertips (10th ed).
New York: American Geriatrics Society.

Schweizer, A., Hughes, C., O’Neil, M., & O’Neil, C. (2005). Managing urinary tract infections in nursing homes:
a qualitative assessment. Pharmacy World and Science, 27, 159-165.

Warren, J. (2001). Catheter-associated urinary tract infections. International Journal of Antimicrobial Agents,
17(2001), 299-303.
Hôpital régional de Sudbury Regional Hospital

CELLULITIS CARE MAP

INCLUSION CRITERIA:
9 Acute Mild/Moderate Cellulitis (inflammation & redness)
9 Fever (temperature greater than/equal to 38.0°C)
9 Mild/Moderate Pain associated with Cellulitis

EXCLUSION CRITERIA:
8 Chronic Cellulitis
8 Suspected necrotizing fasciitis, osteomyelitis, or septic arthritis
8 Infected diabetic or decubitis ulcers
8 Postoperative wound infections
8 Orbital Cellulitis

TESTS (Medical Directive # EDOS01)

• Bloodwork: CBCD, Electrolytes, Urea, Creatinine, Random Glucose, Calcium
• Blood Cultures X 2 if temperature greater than/equal to 38.0°C
• Wound Care swab from infected site
• Baseline & daily INR level if patient on Warfarin (Coumadin) and receiving fluoroquinolones antibiotics

ASSESSMENT
• Vital Signs (temperature, pulse, blood pressure, respiration, oxygen saturation)
• Postural Vitals – Lying down for full 5 minutes and Standing (High Fowler’s if unable to stand) for full
2 minutes
• Mental Status including any changes from baseline
• Hydration Status (mucus membranes)
• C/O pain, type and location
• Affected area of Cellulitis (mark & measure area, drainage)

TREATMENT OPTIONS (Medical Directive # EDOS04)

• Saline lock
• Intervenous therapy

MEDICATIONS*********CHECK ALLERGIES & MEDICATION COMPATIBILITY******

(Medical Directive # EDOS03)
FIRST LINE ORAL PARENTERAL
Cephalexin 500mg QID X 7 days (max) or until physician r/a ---
Ceftriaxone 1gm daily X 7-10 days

SECOND LINE
Cloxacillin 500mg QID X 7 days (max) or until physician r/a ---
Clindamycin 300 – 450 mg QID X 7 days (max) or until physician r/a ---

MEDICATIONS*********CHECK ALLERGIES & MEDICATION COMPATIBILITY******

(Medical Directive # EDOS03)
• Acetaminophen (Tylenol) 325-975mg po (650mg pr) q4hrs prn
Hôpital régional de Sudbury Regional Hospital

ONGOING MEASURES
• Review wound care C&S results & adjust medications accordingly
• Monitor and mark the border of the affected area daily. Notify LTC if affected area is
increasing
• Nutrition – Regular diet or as ordered (encourage fluids unless contraindicated)
• Activity as tolerated – if non-ambulatory patient ensure repositioning q2hrs
• Physiotherapy
• Occupational Therapy

REFERENCES

Dong, S., Kelly, K., Oland, R., Holroyd, B., Rowe, B. (2001). ED Management of Cellulitis: A review of Five
Urban Centers. American Journal of Emergency Medicine, 19(7), 535-540).

Murray, H., Stiell, I., & Wells, G. (2005). Treatment failure in emergency department patients with cellulitis.
Canadian Journal of Emergency Medicine, 7(4), 228-234.

Rosser, W., Pennie, R., Pilla, N., and the Anti-infective Review Panel. (2005). Anti-infective guidelines for
community-acquired infections. Toronto: MUMS Guideline Clearinghouse.

Seaton, R., Bell, E., Gourlay, Y., & Semple, L. (2005). Nurse-led management of uncomplicated cellulitis in the
community: evaluation of a protocol incorporating intravenous ceftriaxone. Journal of Antimicrobial
Chemotherapy, 55, 764-767.
Hôpital régional de Sudbury Regional Hospital

DEHYDRATION CARE MAP

INCLUSION CRITERIA:
9 Loss of appetite/decreased fluid intake
9 Nausea/Vomiting
9 Diarrhea
9 Dizziness
9 Fever (temperature greater than/equal to 38.0°C)
9 Decreased urine output

EXCLUSION CRITERIA:
8 Increased confusion/delirium
8 Change in mental status
8 Severe Vomiting & Diarrhea

TESTS (Medical Directive # EDOS01)

• Bloodwork: CBCD, Electrolytes, Urea, Creatinine, Random Glucose, Calcium
• ECG
• If febrile, include Fever Care Map

ASSESSMENT
• Vital Signs (temperature, pulse, blood pressure, respiration, oxygen saturation)
• Postural Vitals – Lying down for full 5 minutes and Standing (High Fowler’s if unable to stand) for full
2 minutes
• Mental Status including any changes from baseline
• Hydration Status (mucus membranes)
• Urine output (amount, colour)
• C/O pain, type and location

TREATMENT OPTIONS (Medical Directive # EDOS04)

• Oxygen therapy
• Saline lock
• 500 cc NS bolus. Repeat x 1 if chest is clear (no adventitia). Exercise caution if cardiac history.

MEDICATIONS *******CHECK ALLERGIES & MEDICATION COMPATIBILITY******

(Medical Directive # EDOS03)

ONGOING MEASURES
• Nutrition – Regular diet or as ordered. Encourage fluids unless contraindicated. Consider requesting
cranberry juice as prophylaxis for development of UTI.
• Activity as tolerated – if non-ambulatory patient ensure repositioning q2hrs
• Physiotherapy
• Occupational Therapy
Hôpital régional de Sudbury Regional Hospital
REFERENCES

Bryant, H. (2007). Dehydration in older people: Assessment and Management. Emergency Nurse, 15(4), 22-26.

Feinsod, F., Levenson, S., Rapp, K., Rapp, M., Beechinor, E., & Liebmann, L. (2002). Dehydration in Frail,
Older Residents in Long-Term Care Facilities, Journal of American Medical Directors Association,
November/December, 371-376.

Hamilton, S. (2001). Detecting Dehydration & Malnutrition in the elderly. Nursing2001, 31(12), 56-57.

Mentes, J. (2006). Oral Hydration in Older Adults. The American Journal of Nursing, 106(6), 40-49.
Hôpital régional de Sudbury Regional Hospital

SHORTNESS OF BREATH – MILD/MODERATE CARE MAP

ASTHMA and/or MILD COPD

INCLUSION CRITERIA:
9 Mild/Moderate Shortness of Breath
9 Oxygen saturations greater than/equal to 90% unless known COPD
9 Known Asthmatic
9 Audible wheezing
9 Dyspnea at rest, cough, congestion

EXCLUSION CRITERIA:
8 Severe Shortness of Breath
8 Oxygen saturations less than 90% unless known COPD
8 Laboured respirations
8 Tachycardic
8 Agitated, diaphoretic, cyanotic
8 Difficulty speaking
8 Exhausted, confused

TESTS (Medical Directive # EDOS01, EDOS02)

• Bloodwork: CBCD, Electrolytes, Urea, Creatinine, Random Glucose, Calcium, ECG
• Peak flows (pre & post X 3)
• Outpatient Chest X-ray

ASSESSMENT
• Vital Signs (temperature, pulse, blood pressure, respiration, oxygen saturation)
• Postural Vitals – Lying down for full 5 minutes and Standing (High Fowler’s if unable to stand) for full
2 minutes
• Mental Status including any changes from baseline
• Hydration Status (mucus membranes)
• Degree of dyspnea
• Chest sounds, air entry, respiratory effort
• C/O pain, type and location
• Caution in patients with known active tuberculosis or underlying chronic suppurative lung disease
(bronchiesctasis, cystic fibrosis) as potential risk for increased complications
• Caution in patients with immunosuppressed state (HIV, immunosuppressive or antineoplastic drugs,
haematologic malignancy, organ transplant recipient) as potential risk for increased complications

TREATMENT OPTIONS (Medical Directive # EDOS04)

• Oxygen therapy ***if known CO2 retainer titrate O2 to maintain between 88-92%***
• Saline lock
Hôpital régional de Sudbury Regional Hospital

MEDICATIONS *******CHECK ALLERGIES & MEDICATION COMPATIBILITY******

(Medical Directive # EDOS03)
• Salbutamol (Ventolin) inhaler (100mcg/puff) with spacer and mask- 4 to 8 puffs inhaled q15-20 minutes
for 3 doses OR
• Salbutamol (Ventolin) nebulizer (5mg/ml) – use 1ml in 3ml 0.9% normal saline q15-20 minutes for
3 doses

AND

• Ipratropium (Atrovent) inhaler (20mcg/puff) with spacer and mask – 4 to 8 puffs inhaled q15-20
minutes for 3 doses OR
• Ipratropium (Atrovent) nebulizer (250mcg/ml) use (1 to 2ml) in 3ml 0.9% normal saline q 15-20
minutes for 3 doses

AND

• Prednisone 50mg tablet X 1 dose OR

• Methylprednisolone (Solu-Medrol) 40 to 125mg IV; dilute in 50mL D5W or 0.9% normal saline X 1
dose over 15-30 minutes.

ONGOING MEASURES
• Nutrition – Regular diet or as tolerated (encourage fluids unless contraindicated)
• Activity as tolerated – if non-ambulatory patient unsure repositioning q2hrs
• Physiotherapy
• Occupational Therapy
• Spirometry

REFERENCES

Beveridge, R., Grunfeld, A., Hodder, R., & Verbeek, P. (1996). Guidelines for the emergency management of
asthma in adults. Canadian Medical Association Journal, 155(1), 25-37.

Lozano, P., Schaefer, J., Stout, J., Wagner, E., & Weiss, K. (2003). Interventions to improve the management of
asthma in primary care settings. Cochrane Database of Systematic Reviews, 4, 1-6.

Mackey, D., Myles, M., Spooner, C., Lari, H., Tyler, L., Blitz, S., et al. (2007). Changing the process of care and
practice in acute asthma in the emergency department: experience with an asthma care map in a regional
hospital. Canadian Journal of Emergency Medicine, 9(5), 353-365.

Ontario Lung Association Emergency Department Asthma Pathway. (2009). Medication Guidelines for
Emergency Management of Adult Asthma. Retrieved October 14, 2009, from
http://www.on.lung.ca/Health-Care-Professionals/EDACP/resources/medication_guidlines.pdf

RNAO Nursing Best Practice Guideline. (2007). Adult Asthma Care Guidelines for Nurses: Promoting Control
of Asthma. Retrieved October 14, 2009, from
http://www.rnao.org/Storage/27/2207_Asthma_Supplement_-_FINAL.pdf
Hôpital régional de Sudbury Regional Hospital

To, T., Cicutto, L., Degani, N., McLimont, S., & Beyene, J. (2008). Can a Community Evidence-based Asthma
Care Program Improve Clinical Outcomes. Medical Care, 46(12), 1257-1266.