Running head: COMPREHENSIVE CASE STUDY
Comprehensive Case Study
Georgina Crookes
University of Arizona
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COMPREHENSIVE CASE STUDY
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Background Information
The patient of this case study includes a 42-year old woman admitted to the medicalsurgical floor due to septic shock. The patient presented in the emergency department with her
primary complaint being that she felt “very sick for the past couple of days.” The patient reports
having had no surgical history prior to hospitalization and the only medical history was cellulitis
a couple of years ago. After performing a CBC, CMP and a urinalysis, the patient was diagnosed
with septic shock, acute kidney injury and a UTI. She patient has no known drug allergies and is
a full-code status.
Her background includes that she is a member of the Tohono O'odham nation and has
resided on the reservation for the past 30 years. She lives with her mother, sister and two nieces.
The patient is a counsel representative for the district and speaks of how happy she is in her job.
The patient talks about the tribe and how closely knit the community is and how supportive they
have been. The patient states her role in her family is that she is a caregiver. She spoke of her
younger sister being incarcerated and having to take care of her nieces while she is away, but
how willing she was to take on the job. While being hospitalized she said she is not worried
about how her condition has affected things at home because of how loving and supportive her
family is. Developmentally the patient is appropriate as she is a productive member in her
community and takes on the maternal role. She responded very appropriately and thoroughly
which indicated she had proper language/ mental development. According to Erik Erikson’s
psychosocial theory the patient is in the generativity versus stagnation stage. The patient should
be considered to be generative due to her having established a successful career and family. The
patient seems to have an understanding of the “big picture” of life, which is an important aspect
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COMPREHENSIVE CASE STUDY
at this stage. (Potter, Perry, Stockert, & Hall, 2013). The patient denies any history of tobacco,
alcohol use, but does have a history of recreational cocaine use. Although she lives on the
reservation with a supportive mix of people she still interacts with individuals that are negative
influences. When exposed to a more negative crowd of people she was susceptible to doing
recreational drug use.
Physiology
Many organ systems are affected during septic shock since this disease process is a
systemic wide infection. The two major organ systems that this case study focuses on are the
urinary system and cardiovascular system.
The first organ system affected in this patient’s case would be the renal/ urinary system.
The kidneys are two organs that lay in the posterior region of the abdominal cavity. They are
responsible for maintaining a stable environment for cell and tissue metabolism. The kidneys
specific functions include: metabolic waste products excretion, acid-base regulation, solute and
water transport balance and nutrient conservation. Additionally, the functional unit of the kidney
is called the nephron; its functions specifically include regulating the concentration of water and
soluble substances like sodium salts by filtering the blood, reabsorbing what is needed, and
excreting the rest as urine. From the kidneys urine travels down the two ureters into the bladder.
The bladder is responsible for collecting urine from the kidneys and then excreting it through the
urethra. The urethra extends from inside the body to an opening on the outside the body where
urine exits in a process called urination (McCance, Huether, Brashers, and Rote, 2014).
Additionally, the cardiovascular system has been affected which includes the heart, the
blood vessels and all of the circulating blood. The heart is the organ responsible for pumping the
blood to the different areas of the body. The blood vessels are the means of transportation in
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COMPREHENSIVE CASE STUDY
which the blood travels to throughout the entire body. Blood contains RBC’s, WBC’s, platelets
and plasma responsible for maintain homeostasis of nutrients, wastes, and gases. With each
heartbeat the heart contracts and relaxes. The heart receives deoxygenated blood, passes it
through the lungs to become oxygenated and then pumps out the oxygenated blood to be
circulated. The ejection fraction is the percentage of blood leaving your heart each time it
contracts. The stroke volume is the amount of blood ejected by the left ventricle in one
contraction and that is multiplied by the heart rate per minute to get the cardiac output. All of
these factors are important for maintaining adequate circulation. Blood pressure is the measure of
the pressure exerted by blood against the walls of the arterial system. This is most greatly
affected again by the cardiac output, but also by the systemic vascular resistance, which opposes
the movement of blood (Lewis et al., 2014).
Pathophysiology
Sepsis is a systemic inflammatory response to a pathogen. “Septic Shock then occurs in
the presence of sepsis but additionally includes hypotension and inadequate tissue perfusion. The
three major pathophysiological effects of septic shock include: vasodilation, misdistribution of
blood and myocardial depression” (Lewis et al., 2014, p. 1637).
Suspected organisms causing septic shock are gram-negative and gram-positive bacteria.
The body’s exaggerated immune response to septic shock causes mass inflammation and
coagulation release. “Cytokines are released due to the endotoxins, along with tumor necrosis
factor (TNF), interleukin-1 (IL-1), and other proinflammatory mediators that act through
secondary mediators such as platelet-activating factor, IL-6 and IL-8. The release of plateletactivating factor results in the formation of microthrombi and obstruction of the
microvasculature” (Lewis et al., 2014, p. 1636). The results of this mass release include
COMPREHENSIVE CASE STUDY
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widespread vasodilation, platelet clumping causing endothelium damage and adhesion.
“Decreased ejection fraction occurs causing ventricle dilation to increase stroke volume. This
high cardiac output and low systematic vascular resistance (SVR) leads to development of
hypotension and MODS,” (Lewis et al., 2014, p. 1637). Though septic shock is a complex
condition that consumes many resources “approximately 500,000 cases of septic shock can be
expect annually in the United States,” (Giuliano & Kleinpell, 2005, p. 140). Clinical
manifestations of septic shock include fever, chills, irritability, fatigue, tachycardia, hypotension,
and hyperventilation (McCance et al., 2014).
The patient presented into the emergency department with a UTI of which she had no
knowledge about. “During their lifetime, at least 20% of women develop at least one UTI,”
(Lewis et al., 2014, p.1064). Common symptoms of a UTI would include: dysuria, frequent
urination, lower abdominal pain, cloudy urine and a mild fever (McCance et al., 2014).
Unfortunately, the patient went undiagnosed without antibiotics for a while and the infection
then spread up into the kidneys causing pyelonephritis. This acute, severe infection progressed
even further spreading into her blood stream, which put the patient into septic shock.
The urinary tract area tends to normally be sterile due to the low level of acidity and
abundant glycoproteins that interfere with the growth of bacteria (McCance et al., 2014). Many
times organisms, such as E.coli, are introduced to the urethral opening and travel up causing an
UTI. “Precipitating factors include sexual intercourse, catherization, and improper wiping,”
(Lewis et al., 2014, p. 1065). Also, a woman’s urethra is much shorter than a males being only 3
to 4 centimeters versus 18 to 20 centimeters, which leaves women much more susceptible to
UTIs.
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COMPREHENSIVE CASE STUDY
The patient additionally was diagnosed with acute kidney injury as her signs showed
creatinine levels of 3.2, 1.6 and 2.0. The patient initially had BUN levels of 19 and 23, but levels
increased to 26 (see Appendix A for rest of laboratory results). Acute kidney injury is caused
from a multitude of issues but for this patient it was likely due to “toxic/inflammatory injury to
kidney cell that resulted in alteration in the kidney function,” (McCance et al., 2014, p. 1360).
Another possible reason for the kidney injury is due to the lack of tissue perfusion that septic
shock places on the body. The inability to deliver oxygen to vital organs can caused ischemia
resulting in injury. The patient has had no surgeries or procedures previously so there is no
relationship of the current disease processes with the patient’s history.
Physician’s Orders
The patient is currently on orders for a renal diet due to her kidney dysfunction. She is
being monitored on her fluid intake and is having low sodium, phosphorous and protein meals.
Her activity order is for her to be up to chair and is allowed to walk ad lib. She should have
assistance when ambulating due to the increased risk for postural hypotension related to possible
hypovolemia. She currently has the use of SCDs for prevention of a venous thrombolytic event
(VTE) with a continuous order for pulse oximetry. Daily weights were ordered for the patient
due to her kidney dysfunction causing fluid excess. She was on vitals every 15 minutes including
monitoring mean arterial pressure (MAP) for the first four hours, then every 30 minutes for the
next eight hours, then taken per unit routine. Patient is on continuous cardiac monitoring since
she is at risk for hypotension; she additionally is on continuous central venous pressure (CVP)
monitoring. She is on 2 liters of oxygen via nasal cannula to promote optimal oxygen delivery.
The physician ordered removal of all rings and constricting jewelry prior to fluid resuscitation
due to risk of swelling.
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COMPREHENSIVE CASE STUDY
Medications
The patient is currently on a multitude of scheduled medications, continuous and
PRN medications for the treatment of her septic shock, acute kidney injury and UTI. There are a
few medications, which are vital for proper treatment and prophylactic measures (See Appendix
C for the rest of the patient’s medications).
Enoxaprin (Lovenox) is a low-molecular weight heparin that is used as an anticoagulant.
It is being used for this patient due to the increased risk for clotting. Septic shock causes
microthrombi to form so this medication will decrease the chance of a VTE. The nursing
implications include assessing for signs of bleeding and hemorrhage including nosebleeds,
unusual bruising, black stools, hematuria among others. Patient responded well to the medication
and did not report any side effects.
Amoxicillin-clavulanate (Augmentin) is a broad-spectrum drug that is being used for the
treatment of septic shock and her UTI. It will bind to the bacterial cell walls causing cell death.
The nursing implications include monitoring bowel function. Diarrhea, abdominal cramping,
fever, and bloody stools are signs of pseudomembranous colitis. Patient responded well to the
medication and did not report any side effects.
Piperacillin/tazobactam (Zosyn) is a broad-spectrum drug that is being used for the
treatment of her UTI. This medication will also bind to bacterial cell wall membrane, causing
cell death. The nursing implications include monitoring bowel function. Diarrhea, abdominal
cramping, fever, and bloody stools could be a sign of pseudomembranous colitis. Assess for skin
reactions including rash, fever, edema, mucosal erosions or ulcerations, and red or inflamed eyes.
The patient responded well to the medication and did not report any side effects.
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COMPREHENSIVE CASE STUDY
Lactated Ringers is a mineral and electrolyte replacement therapy that is being used for
fluid resuscitation. This medication will help improve the patient’s hypovolemic state caused by
septic shock. The purpose is to increase her blood pressure and therefore improve tissue
perfusion. The nursing implications include assessing for fluid balance (intake and output, daily
weight, edema and lung sounds). The patient responded well to the medication as it was
continuous and did not report any side effects.
Diagnostic Tests
Renal ultrasounds are used to “detect renal or perineal masses. This noninvasive
procedure involves passing sound waves into body structures and recording images as they are
reflected back,” (Lewis et al., 2014, p. 1059). The patient had suspected acute kidney injury and
performing a renal ultrasound would allow a better look. Results showed hepatomegaly
(enlargement of the liver), cholelithiasis (gallstones), and mild extrahepatic biliary ductal
dilation.
A MRI without CT is useful for “visualization of kidneys and the gallbladder. Computer
generated images rely on radiofrequency waves and alteration in magnetic field,” (Lewis et al.,
2014, p. 1059). The scan was used due to suspected presence of gallstones and the images would
reveal as such. The results indeed showed gallbladder stones with no inflammation present.
The third test is a urinalysis, which “confirms suspected urinary tract infection and
identifies causative organisms,” (Lewis et al., 2014, p. 1057). The UTI can show the presence of
bacteria in the urine, which will help with the diagnosis. The urinalysis revealed hazy urine with
bacteria >10^5/mL, slight blood, but no glucose or ketones. The results of this test are significant
because it indicates that the patient should be placed on an antibiotic and indicated that the UTI
caused the septic shock (See Appendix B for information on all diagnostic tests).
COMPREHENSIVE CASE STUDY
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Nursing Diagnoses and Review of Literature
The first nursing diagnosis for the patient is ineffective tissue perfusion related to
systemic vasodilation secondary to septic shock as evidence by the patient’s hypotension. The
goal is to increase tissue perfusion and the SMART outcome is that the patient will have a
systolic blood pressure equal to or higher than 90 mmHg by the end of shift. The first
intervention would be to administer oxygen to the patient due to the increased tissue oxygen
requirements that septic shock places on the patient’s body. During septic shock, lactic acid
levels increase due to the body transferring to using anaerobic metabolism. “Clearance of lactic
acid levels following resuscitation is associated with survival emphasizing the importance in
increasing systemic oxygen delivery in restoring tissue perfusion and enhancing outcome during
septic shock,” (Tuchschmidt, Fried, Astiz, & Rackow, 1992, p. 219). The second intervention
would be to examine the condition of the skin, mucosa and nails for inadequate tissue perfusion.
The conditions of these are useful in determining whether cyanosis may be present. Checking for
changes in color and temperature are simple yet effective for preventing further oxygen
desaturation (Potter et al., 2013). The third intervention would be continuous monitoring of
patient including blood pressure, oxygen saturation and electrocardiogram. The rationale is that
these parameters are useful for the identification and treatment of septic shock.
The research article by Giuliano and Kleinpell (2005) showed the importance of using
continuous monitoring parameters for critically ill patients with sepsis. This descriptive study’s
purpose was to gain an understanding of both physicians and critical care nurses’ preferences
with regards to their use of monitoring parameters with septic patients. The participant’s survey
ranked order from 1-4, the different parameters of physiologic monitoring including: continuous
ECG, invasive blood pressure, pulmonary artery pressure and arterial oxygen saturation. These
COMPREHENSIVE CASE STUDY
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parameters were selected because they were “recommended by practice and professional
standards, commonly available for standard critical care monitoring, used by critical care staff,
and broadly reflective of the pathophysiologic changes that often occur early in the course of the
septic disease process,” (Giuliano & Kleinpell, 2005, p.143). The results showed that out of the
617 professionals, “the majority of the respondents agreed that all four types of continuous
physiologic monitoring, ECG (76.7%), invasive blood pressure (75.2%), pulmonary artery
pressures (61%), and SpO2 (41.8%) are necessary in the care of patients with sepsis,” (Giuliano
& Kleinpell, 2005, p.146). The implications of this study further proved the importance and
value of these continuous physiologic parameters. This patient would benefit greatly from the
use of monitoring due her critical condition. Monitoring can be considered a prophylactic
measure because this would allow for nurses to be aware of her condition and notify the
physician before her condition worsens.
Finally, the outcome was met due to the goal being reached with a systolic pressure equal
to or above 90mmHg by the end of the shift.
The second nursing diagnosis for this patient is increased risk for infection r/t decreased
immune system and increased WBCs. The goal is to prevent increased risk for infection and the
SMART outcome is that the patient will have white blood cells within the 4.0-11.0 k/mm3 range
by discharge. The first intervention will be to teach the patient signs and symptoms of infection.
“Patients need to be able to recognize sources of infection and understand measures used to
protect themselves” (Potter et al., 2013, p. 398). The rationale is that if the patient learns signs of
infection including fever, erythema and inflammation then the patient will be able to notify the
provider before the infection worsens. The second intervention is to encourage the patient to eat
a well-balanced diet high in essential nutrients; provide dietary supplements if indicated. The
COMPREHENSIVE CASE STUDY
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rationale is that patients with poor nutritional status could be in a state of immune
unresponsiveness and therefore are more susceptible to infection (Ackley & Lawdwig, 2013).
The third intervention is to promote good hand washing by patient and staff. “A major
component of patient and worker protection is hand hygiene. Contaminated hands of health care
workers area primary source of infection transmission in health care settings,” (Potter et al.,
2013, p. 410)
The author Hughes (2006) looks at proper hand washing techniques to promote infection
control in hospitals. Hand washing is considered to be one of the simplest yet most effective
ways at preventing infection spread. Proper hand-hygiene involves using soap and rubbing them
vigorously together for at least 15 seconds using soap. The friction of rubbing hands together
removes soil and transient organisms from the hands. Including scrubbing underneath the
fingernails is important because nails have shown to increase subungual bacteria, which will
again put the patient at risk. The CDC estimates that every year in the United States 7% to 10%
of patients contract a hospital-acquired infection resulting in approximately 80,000 deaths
(Hughes, 2006). Health-care professionals and patients should abide by strict hand hygiene
guidelines and ensure it as a priority for ultimately the safety of the patient and others.
Finally, the outcome has not been met due to inability to assess because of the time frame
allotted.
The third nursing diagnosis is excess fluid volume related to kidney dysfunction as
evidence by decreased urine output and increased weight gain. The general goal is to prevent
furthering of excessive fluid volume and the SMART outcome is that the patient will not gain
any more weight by the time of discharge. The first intervention is to monitor I/Os “measuring
and recording all liquid intake and output during a 24-hour period is an important aspect of fluid
COMPREHENSIVE CASE STUDY
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balance assessment. If intake is substantially greater than output then the patient may be gaining
excessive fluid,” (Potter et al., 2013, p. 898). This patient’s intake has been severely greater than
her output, so monitoring I/O’s is important. The second intervention is daily weighing, “daily
weights are an important indicator of fluid status. Each kilogram of weight gained or lost
overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in
the amount of total body fluid. When weighing the patient she needs to wear the same clothes
and compare the weight to that of the day before for comparison,” (Potter et al., 2013, p. 898 ).
This patient in particular needs to be monitored due to her severe fluid retention. The third
intervention is to perform lung auscultation since excessive fluid volume can occur in the lungs
as well as other places in the body. Due to this patient’s decreased kidney functioning the fluid
can travel to the lungs. Listening to lung sounds for crackles, monitoring respirations for effort
will help. This patient in particular already has decreased tissue perfusion due to sepsis;
monitoring lung sounds can prevent orthopnea (Ackley & Lawdwig, 2013).
The article by Yerram, Karuparthi and Misra (2010) looks at preventing fluid overload in
patients with acute kidney injury (AKI) by monitoring intake and output. AKI is thought to have
occurred because of hypotension causing renal hypoperfusion, which leads to ischemia. The fluid
resuscitation is extremely important in patients with septic shock due to the relative
hypovolemia, but it is important to note that fluid overload is considered “almost inevitable” for
patient with AKI. “To mitigate the development of fluid overload, and its adverse effects, a
strategy of careful early guided fluid resuscitation to achieve hemodynamic stability, followed by
careful reassessment of fluid status should be followed,” (Yerram, Karuparthi, & Misra, p. 352).
Finally, the outcome has not been met due to inability to assess because of the time frame
allotted.
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COMPREHENSIVE CASE STUDY
References
Ackley, B. J. & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). St. Louis, MO: Mosby Elsevier.
Giuliano, K., & Kleinpell, R. (2005). The sse of common continuous monitoring parameters.
AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 16(2), 140-148
Hughes, N. (2006). Health & safety: Handwashing. The American Journal of Nursing, 106(7),
96-96
McCance, K. L., & Huether, S. E. (2014). Understanding pathophysiology (7th ed.). St. Louis:
Mosby Elsevier.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing (8th
ed.). St. Louis, MO: Elsevier Mosby.
Tuchschmidt, J., Fried, J., Astiz, M., & Rackow, E. (1992). Elevation of cardiac output and
oxygen delivery improves outcome in septic shock. Chest, 102(1), 216-220.
doi:10.1378/chest.102.1.216
Yerram, P., Karuparthi, P., & Misra, M. (2010). Fluid overload and acute kidney injury.
Hemodialysis International, 14(4), 348-354. doi:10.1111/j.1542-4758.2010.00498.x
Vallerand, A., & Sanoski, C. (2013). Davis's drug guide for nurses. Philadelphia: F. A. Davis
Company.
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COMPREHENSIVE CASE STUDY
Appendix A:
Laboratory Tests
Lab Test
WBC
Neutrophils
(ANC)
Lymphocyte
Monocytes
Hemoglobin
(Hgb)
Hematocrit
(Hct)
Platelets
Serum Na
Serum K
Serum Cl
Serum CO2
BUN
Creatinine
Normal
Value
4.0 11.0
k/mm3
35-80%
10-45%
3-15%
13.0 - 18.0
g/dL
41.0 - 54.0
%
130-450
K/uL
135 - 145
mmol/L
3.5 - 5.2
mmol/L
101 -111
mmol/L
14-32
mmol/L
7-20
mg/dL
0.6- 1.5
mg/dL
Glucose
65-99
mg/dL
Ca
8.7 - 10.5
mg/dL
Mg
GFR
1.8 - 2.5
mg/dL
<60
Date performed
and result
11/07
17.6
74.5
10.8
8.8
12.9
Pathophysiological explanation of each
abnormal value
Leukocytosis due to septic shock increases
levels of WBC. Increased infection causes
cascade of WBC’s.
Within normal limits
135
Within normal limits
Within normal limits
Decreased hemoglobin due to septic shock or
due to medication
Decreased hemoglobin due to septic shock or
due to medication
DIC or thrombocytopenia occurs during sepsis
shock due to release of platelet activating
factor
Within normal limits
3.2
Kidney dysfunction leads to hypokalemia
107
Within normal limits
19
Within normal limits
37.5
271
37
High levels indicate kidney injury and UTI
3.2
High levels indicate acute kidney injury
129
1.8
Evidence shows that septic shock induces
hyperglycemic response. Increased glucose
could also be due to food and/or medication
Calcium is low due to improper functioning of
the kidneys. The kidneys along with PTH
regulate the levels.
Within normal limits
16
Low levels indicate kidney injury
7.7
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COMPREHENSIVE CASE STUDY
Appendix B:
Diagnostic Tests
Name of Test
MRI without contrast
Date of Test
11/11/2014
Renal Ultrasound
11/09/2014
Chest X-Ray
11/11/2014
Urinalysis
11/07/2014
Purpose of Test
To check for
gallstones
To check for renal
dysfunction
Evaluation for
pneumonia
To check for UTI
Test Results
Gallbladder stones
with no inflammation
-hepatomegaly
-cholelithiasis
-mild extrahepatic
biliary ductal dilation
Negative for
pneumonia
-hazy urine with
bacteria >10^5/mL
reveals patient is
positive for UTI
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COMPREHENSIVE CASE STUDY
Appendix C:
Medications
Name
Dose, Route,
Due,
Frequency
Class/
Mechanism
of Action
Most
Common or
Serious Side
Effects
enoxaprin
Lovenox
.4mL subQ
qday @0900
Anticoagula
nt.
MOA:
antithrombin
-dependent.
Bleeding,
hemorrhage,
anemia
heparin flush
3mL IV flush
q12h
@0900 &
@2100
Anticoagula
nt
MOA:
prevents the
formation of
blood clots.
The flush
prevents
blockage in
the central
line
Bleeding,
hemorrhage
Contraindicatio
ns/
Major
Interactions
Increased risk of
bleed with
NSAIDs,
penicillins,
warfarin,
ticlopidine,
abcoximabid,
dextran,
thrombolytics,
clopidogrel and
drugs that affect
platelet function
and coagulation
Acute
Hemorrhage,
Decreased
Platelets due to
the Medication
Heparin,
Decreased Blood
Platelets
Nursing
Interventions
Patient
Teaching
Assess
hemorrhage
and bleed S/S.
monitor CBC,
platelet ct,
stools for
occult blood.
Protamine
sulfate 1 mg
per 1 mg of
enoxaparin is
antidote for
overdose
Assess for
signs of
bleeding and
hemorrhage
(bleeding
gums;
nosebleed;
unusual
bruising;
black, tarry
stools;
hematuria.
aPTT test prior
to therapy.
Protamine
Sulfate is the
antidote for
overdose
Monitor for
bleeding,
bruising
and
increased
thrombosis
Advise
patient to
report any
symptoms
of unusual
bleeding or
bruising to
health care
professional
immediatel
y. Instruct
patient not
to take
medications
containing
aspirin or
NSAIDs
while on
heparin
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COMPREHENSIVE CASE STUDY
piperacillin/
tazobactam
Zosyn
Antiinfective
piperacillin:
Binds to
bacterial cell
wall
membrane,
causing cell
death
tazobactam:
Inhibits betalactamase,
an enzyme
that can
destroy
penicillins.
confusion,
dizziness,
headache,
insomnia,
lethargy,
diarrhea,
constipation,
N/V,
bleeding,
leukopenia,
pseudomembranous
colitis, rash
May alter
excretion of
lithium.
Probonecid may
cause decreased
renal excretion
and increased
blood levels.
Monitor bowel
function for
cramping,
diarrhea due to
pseudomembranous
colitis. Obtain
specimens for
culture and
sensitivity
prior to
initiating
therapy.
amoxicillinclavulanate
Augmentin
500mg125mg PO
1tab q12h
@0900
@2100
Bactericidal
MOA: binds
to bacterial
cell wall
causing cell
death.
Resistance
of betalactamase
Pseudomembranous
colitis,
diarrhea,
N/V, hepatic
dysfunction,
vaginal
candidiasis,
rash
Hypersensitivity
to penicillins or
clavulanate. May
increase effects
of warfarin, May
decrease
effectiveness of
oral
contraception
Monitor bowel
function for
cramping,
diarrhea due to
pseudomembranous
colitis.
Acetaminoph
en
PO 650mg=
2tabs q4h
PRN
Antipyretic
MOA:
Inhibits the
synthesis of
prostaglandi
ns that may
serve as
Hepatotoxici
ty (high
doses), Rash,
uticaria,
neutropenia,
StevensJohnson
Concurrent use
of NSAIDS may
increase the risk
of adverse renal
effects.
2.25g IV
Piggyback,
q6h,
200mL/hr
@0300,
@0900,
@1500,
@2100
therapy.
Caution
patient to
notify
health care
professional
if fever and
diarrhea
occur,
especially if
stool
contains
blood, pus,
or mucus.
Instruct
patient to
notify
health care
professional
immediatel
y if
diarrhea,
abdominal
cramping,
fever, or
bloody
stools occur
and not to
treat with
antidiarrhea
ls without
consulting
health care
professional
s.
Assess overall Advise
health status
patient to
and alcohol
avoid
usage before
alcohol (3
administering or more
acetaminophen glasses per
. Evaluate
day
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COMPREHENSIVE CASE STUDY
mediators of
pain and
fever,
primarily in
the CNS
Lactated
Ringers
Injection
1,000 mL IV
infusion @60
ml/hr
continuous
Ondanestron
(Zofran)
2mL IV push
q6h PRN
Mineral and
electrolyte
replacement
syndrome
Hypervolemi
a Infusion
site
reactions,
MOA:
including
hydration
Infection at
therapy
the site of
injection,
extravasatio
n and
infusion site
anesthesia
Antiemetic
Headaches,
dizziness,
MOA:
drowsiness,
blocks the
fatigue,
effects of
weakness,
serotonin at
torsade de
5-HT3
pointes,
receptor sites constipation,
located in
diarrhea, dry
vagal nerve
mouth
terminals
and the
chemorecept
or trigger
zone in the
CNS
Patients with
fluid retention or
those who are
hyponatremic.
Use cautiously in
patients prone to
metabolic, acidbase or
fluid/electrolyte
imbalances
Hypersensitivity,
hepatic
impairment
patient,
concurrent use of
apomorphine,
congenital long
QT syndrome
patients
hepatic,
hematologic,
and renal
function
periodically
during
prolonged,
high-dose
therapy.
Assess fluid
balance (intake
and output,
daily weight,
edema, lung
sounds)
throughout
therapy
increase the
risk of liver
damage) if
taking more
than an
occasional
1-2 doses
Monitor ECG
in patients
with
hypokalemia,
hypomagnesia,
HF,
bradarrhythmi
as, assess for
extrapyramidal
effects,
Advise
patient to
tell nurse
about
irregular
heart beat,
facial
twitching if
they occur
Explain
purpose of
the infusion
and the
importance
of proper
fluid/
electrolyte
balance
COMPREHENSIVE CASE STUDY
I have reviewed the Code of Academic Integrity and can attest that this document is consistent
with the provisions of the code and represents my own original work.
Signed: Georgina Crookes
19