NURS 301 Care Plan sepsis.pdf.pdf

RUNNING HEAD: ROOM 558: SEPSIS

Room 558:

Sepsis

Keri Bennett

Liberty University !

! 2

Student Name: Keri Bennett

Patient Profile Worksheet (Profile Part I)

A. Personal Information

Room #: 558 Gender: Female Ethnicity: Caucusan Age if < 90: 89

Place of Residence: Westminster Canterbury MD: Dr. Cabrera

EmergencyContact: Niece MaritalStatus: Widowed

Admitting Diagnosis: Sepsis

Co-Morbidities: Chronic atrial fibrillation

Date of Admission: 2/01/2018 Date of Surgery: N/A Allergies: Prednisone,

Code Status: DDNR since 2014 changed to full code by patient and approved by her POA

Mental Status: Demented

B. Activity and Nutrition

Diet order: Regular Route/Rate: Oral Last Wt: 63.5kg

Level of Activity (bedrest, up ad lib, BRP, turning): Up ad lib

Level of self-care: Assist x1

C. Nursing Care:

Drainage devices (foley, NGT, JPs, T-tube, etc.): None

NGT Flushes: N/A

Wound care/Dressing (be specific): N/A

IV access (peripheral, central, location, care): Peripheral R forearm, 20G, Medipore tape

and gauze dressing; change Q72H or PRN

IVF: ___________ @_____mL/hr Saline Lock? Yes TPN? No

Frequency of vital signs (including pulse oximetry): Q4H

Frequency of Glucometer: Q6H Supplemental oxygen: 2L OSA: Yes

Falls Risk: High risk

Precautions: OSA precautions, falls risk

! 3

Student Name: Keri Bennett

Most Recent Labs (include date of labs):

Common Hematology/Chemistries/RFTs

Other Pertinent Labs (make sure to document important trends):

Patient is consistently hypertensive with blood pressures in the range of 130/70. She is currently

afebrile but has spiked temperatures at a maximum of 102.3*F in the past without identifiable

cause. Febrile episodes have been brief in length and have been better controlled over the past 36

hours. Respirations on admission were initially elevated at 22 bpm, but have since normalized.

Patient is mildly hypoxic with an O2 saturation of 91% when on room air, but this is resolved

with the administration of 2L oxygen via nasal cannula.

Patient History Worksheet:

Chief Complaint: Encephalopathy and confusion

Lab

Normal range

Patient value

Date/time

Out of range?

WBC

4-10 x 10^9/L

9.7 x 10^9/L

2/07/18 2117

WNL

13.5-17.5 g/dL

12.4 g/dL

2/07/18 2117

WNL

Hct

38.8-50%

36.3%

2/07/18 2117

WNL

Plts

50-400 x 10^9/L

241 x 10^9/L

2/07/18 2117

WNL

Na+

135-145 mmol/L

138 mmol/L

2/07/18 2117

WNL

K+

3.5-5 mmol/L

3.9 mmol/L

2/07/18 2117

WNL

Cl-

95-105 mmol/L

101 mmol/L

2/07/18 2117

WNL

HC03

18-22 mmol/L

20 mmol/L

2/07/18 2117

WNL

BUN

8-21 mg/dL

22 mmol/L

2/07/18 2117

High

0.6-1.2 mg/dL

1.1 mg/dL

2/07/18 2117

WNL

Glucose

70-100mg/dL

104 mg/dL

2/07/18 1157

High

! 4

Student Name: Keri Bennett

History of Present Illness (discuss clinical course from admission until current date):

The patient, Mrs. H, is a 89 year old caucasian female who presented to the Lynchburg

Emergency Department on 2/01/2018 with mental health status that had declined that day. She is

a resident of Westminster Canterbury and was accompanied by a generational aide. Due to the

patient’s declining mental state, it was not possible to obtain a detailed history from her, ergo

most details about her condition leading up to admission were obtained from the patient’s aide.

Mrs. H had visited the ED the day before; x-rays taken at that time were consistent with

pneumonia, however the patient refused blood work or any further medical intervention and

returned to her home. She was given Levaquin at that time. Per her aide, no fever, chills, or

unusual shortness of breath have been noticed. Mrs. H does have a moderate cough, which

produces small amounts of whitish/yellowish sputum. The patient denies any headache, chest

pain, or blurred vision. She was found to be mildly hypoxic (91% oxygen saturation) upon

examination and her respiratory rate was elevated at 22bmp. She was admitted to the pulmonary

unit of LGH for further evaluation and treatment of suspected sepsis.

Past Medical History

The patient has a history of atrial fibrillation for which she is prescribed Xanthol

Past Surgical History

Carpel tunnel on both hands, cataract surgery, pacemaker placed 2014

Family History

Tobacco: Denies Alcohol: Denies Illegal Drugs: Denies

Occupational Status: Retired

Religious Preference: None listed

! 5

Student Name: Keri Bennett

Cultural Support Needs: Elderly widowed female with advancing dementia. Her closest relative,

her niece, has two small children and lives several hours away in northern Virginia.

! 6

Student Name: Keri Bennett

II. Medications

Student should also have medication cards or book available on clinical.

Include PRNs that have been administered with the last 24 hours.

Medica

tion

Generic

Trade

Rout

Dosa

ge &

Freq

uenc

Category/

Mechanism of

Action

Contraindications /

Cautions

Side Effects

Use for

this

patient

Benztro

pine

Oral

0.5m

BID

Subclass:

Parkinson

Disease/

Dystonia

Mechanism of

Action:

antagonizes

acetylcholine

and histamine

receptors

hypersens. to drug/class/

compon.; pts <3 yo;

glaucoma, angle-closure;

tardive dyskinesia; ileus;

obstructive uropathy;

BPH; caution if

cardiovascular dz; caution

if high environmental

temperature; caution in

elderly pts; caution in

pediatric pts

Serious Reactions

tachycardia; psychosis,

anticholinergic; heat stroke

Common Reactions

xerostomia; constipation;

urinary retention;

tachycardia; sedation;

dyspnea; nausea; vomiting;

flatulence; anorexia;

abdominal pain; rash;

pruritus; dizziness; headache;

nervousness; tinnitus; edema;

blurred vision

Treatme

nt of

dystonia

secondar

y to

dementia

-related

degenera

tion

Cholecal

ciferol

(Vitamin

D3)

oral

2000

units

daily

Subclass:

Vitamins/

Nutritionals;

Osteoporosis 2:

Calcium/

Vitamin D

Mechanism of

Action:

stimulates

intestinal Ca and

PO4 absorption;

stimulates bone

mineralization

(vitamin D)

hypersens. to drug/ class/

compon.; hypercalcemia;

hypervitaminosis D; renal

osteodystrophy; caution if

malabsorption syndrome;

caution if

hyperphosphatemia;

caution if renal stones;

caution if renal

impairment; caution if

cardiovascular dz; caution

if leukemia; caution if

lymphoma; caution if

sarcoidosis

Serious Reactions

hypervitaminosis D;

hypercalcemia;

hypercalciuria;

nephrotoxicity;

hyperphosphatemia

Common Reactions

hypercalcemia; Cr elevated;

hypercalciuria; nausea;

vomiting; anorexia; polyuria;

anemia; weakness; renal

impairment

Dietary

suppleme

Cyclosp

orine

(Restasi

Eyes

drop

DPE

Subclass:

Other

Ophthalmics

Mechanism of

Action:

exact

mechanism of

action

unknown; acts

as a partial

immunomodula

tor, resulting in

tear production

hypersens. to drug/class/

compon.

Serious Reactions

hypersensitivity rxn

Common Reactions

ocular burning; conjunctival

hyperemia; ocular discharge;

lacrimation; ocular pain;

foreign body sensation;

ocular pruritus; ocular

stinging; blurred vision

Treatme

nt of dry

eyes

! 7

Student Name: Keri Bennett

Famotid

ine

Oral

20m

Dail

Histamine-2

(H2) Blockers;

H. pylori/

selectively

antagonizes

histamine H2

receptors

hypersens. to drug/class/

compon. caution if renal

impairment

Serious Reactions

anaphylaxis, angioedema,

toxic epidermal necrolysis,

Stevens-Johnson syndrome,

agranulocytosis, leukopenia

thrombocytopenia,

pancytopenia, seizures, AV

block, arrhythmias, CNS

toxicity, cholestatic jaundice,

hepatitis, pneumonia,

interstitial, QT prolongation

(renally impaired pts)

Common Reactions

headache, dizziness,

constipation, diarrhea, taste

changes, vitamin B12

deficiency (long-term use)

Antihista

mne

Ferrus

sulphate

(Iron)

Oral

350

daily

Subclass:

Minerals; Iron

Homeostasis

Mechanism of

Action:

provides iron,

an essential

component in

hemoglobin,

myoglobin, and

various

enzymes

hypersens. to drug/class/

compon., hemosiderosis,

hemochromatosis,

anemia, non-iron

deficient, infectious

kidney dz, acute, caution

if RA, caution if asthma

or hx, caution if severe

allergies, caution if

refractory anemia, caution

if hemoglobinopathy,

caution if hepatic

impairment, serious

Serious Reactions

anaphylaxis, anaphylactoid

rxn, shock, cardiac arrest,

hypotension, severe,

syncope, tachycardia,

bradycardia, arrhythmias,

bronchospasm, respiratory

arrest, seizures, arthritis

exacerbation or new onset,

hemosiderosis

Common Reactions

flushing, nausea/vomiting,

taste changes, fever/rigors,

dizziness, headache,

diaphoresis, hypotension,

arthralgia/myalgia, pruritus/

rash/urticaria, diarrhea,

abdominal pain, injection site

staining (IM use), injection

site rxn, sterile abscess,

adenopathy, chest pain/

tightness, malaise/weakness,

disorientation, paresthesia

treatmen

t of

anemia,

increase

hemoglo

bin

! 8

Student Name: Keri Bennett

Fluticas

one

Propinat

Nasal

50m

BID

Subclass:

Nasal Sprays,

Corticosteroid

Mechanism of

Action:

exact

mechanism of

anti-

inflammatory

action

unknown;

inhibits

multiple

inflammatory

cytokines;

produces

multiple

glucocorticoid

and

mineralocortico

id effects

hypersens. to drug/class/

compon.; unhealed nasal

septal ulcer; unhealed

nasal wound; caution if

hepatic impairment,

severe; caution if recent

long-term systemic

corticosteroid tx; caution

if measles or varicella

exposure; caution if

untreated local or

systemic infection;

caution if TB infection;

caution if ocular HSV

infection; caution if IOP

incr.; caution if glaucoma;

caution if cataracts;

caution in pediatric pts

(long-term use)

Serious Reactions

hypersensitivity rxn;

anaphylaxis; glaucoma (long-

term use); cataracts (long-

term use);

immunosuppression (long-

term use); hypercorticism

(long-term use); adrenal

suppression (long-term use);

growth suppression (long-

term use, peds pts)

Common Reactions

headache; URI sx; epistaxis;

nasal burning/irritation;

nausea/vomiting; cough;

diarrhea; abdominal pain;

bronchitis; dizziness; nasal/

oral candidiasis; nasal septal

perforation; nasal ulcer

Treanme

nt of

nasal

conjestio

! 9

Student Name: Keri Bennett

Furose

mide

(Lasix)

Oral

10m

daily

Loop diuretic/

inhibits loop of

Henle and

proximal and

distal

convoluted

tubule sodium

and chloride

resorption

hypersensitivity to drug/

class/components; anuria;

hepatic coma; electrolyte

imbalances; caution if

hypersens. to

sulfonamides; caution if

concurrent ototoxic agent

use; caution in elderly pts;

caution in premature

neonates; caution if

hepatic dz, severe; caution

if renal dz, severe; caution

if urinary retention;

caution if arrhythmias;

caution if gout hx; caution

if SLE; caution if diabetes

mellitus; caution if

iodinated contrast

Serious Reactions

hypokalemia, severe;

electrolyte imbalance, severe;

metabolic alkalosis;

hypovolemia/dehydration;

ototoxicity;

thrombocytopenia; anemia,

hemolytic; aplastic anemia;

leukopenia; agranulocytosis;

eosinophilia; thrombosis;

anaphylaxis; vasculitis;

interstitial nephritis;

necrotizing angiitis; Stevens-

Johnson syndrome; toxic

epidermal necrolysis;

erythema multiforme; drug

rxn w/ eosinophilia and

systemic sx; acute

generalized exanthematous

pustulosis; exfoliative

dermatitis; pancreatitis;

cholestatic jaundice; SLE

exacerbation; nephrolithiasis

(pts <4 yo, chronic use)

Common Reactions

urinary frequency; dizziness;

nausea/vomiting; weakness;

muscle cramps;

hypokalemia;

hypomagnesemia;

hypotension, orthostatic;

ALT, AST elevated; blurred

vision; anorexia; abdominal

cramps; diarrhea; pruritus;

rash; hyperuricemia;

hyperglycemia;

hypocalcemia; tinnitus;

paresthesia; photosensitivity;

cholesterol incr.; triglycerides

incr.

Decrease

peripher

al and

plural

edema

! 10

Student Name: Keri Bennett

Hydroc

ortisone

Topic

appli

catio

BID

Subclass:

Corticosteroids,

Topical VII:

Lowest Potency

Mechanism of

Action:

exact

mechanism of

anti-

inflammatory

action

unknown;

inhibits

multiple

inflammatory

cytokines;

produces

multiple

glucocorticoid

and

mineralocortico

id effects

hypersens. to drug/class/

compon.; caution if skin

infection; caution in

pediatric pts

Serious Reactions

HPA axis suppression;

Cushing syndrome;

hyperglycemia; intracranial

HTN (peds pts)

Common Reactions

burning; pruritus; irritation;

dryness; folliculitis;

hypertrichosis; acneiform

dermatitis;

hypopigmentation; perioral

dermatitis; allergic contact

dermatitis; maceration;

secondary infection; skin

atrophy; striae; miliaria

Topical

antiinfla

mitory

Nizoral

Topic

appli

catio

SHA

Subclass:

Seborrhea/

Dandruff;

Antifungals,

Topical

Mechanism of

Action:

inhibits fungal

cell membrane

ergosterol

synthesis

hypersens. to drug/class/

compon.; caution if

hypersens. to sulfites (crm

form)

Serious Reactions

hypersensitivity rxn;

angioedema

Common Reactions

application site rxn; pruritus;

xeroderma; irritation;

burning; alopecia

Antifung

! 11

Student Name: Keri Bennett

Lamicta

Oral

200

BID

Subclass:

Seizure

Disorders;

Bipolar

Disorder

Mechanism of

Action:

exact

mechanism of

action

unknown;

inhibits

voltage-

dependent

sodium

channels,

decreasing

presynaptic

glutamate and

aspartate

release

hypersens. to drug/class/

compon.; avoid abrupt

withdrawal; caution if

hypersens. to antiepileptic

drugs; caution if renal

impairment; caution if

hepatic impairment;

caution if suicide risk;

caution if pregnancy 1st

trimester; caution if PKU

(phenylalanine-containing

forms)

Serious Reactions

rash, severe; Stevens-

Johnson syndrome; toxic

epidermal necrolysis;

angioedema; hypersensitivity

rxn, severe or life-

threatening; drug rxn w/

eosinophilia and systemic sx;

blood dyscrasias; status

epilepticus; withdrawal

seizures if abrupt D/C;

aseptic meningitis; hepatic

failure; suicidality;

depression exacerbation

Common Reactions

dizziness/vertigo; headache;

diplopia; ataxia; nausea/

vomiting; blurred vision;

somnolence; URI sx;

pruritus/rash; back pain;

dysmenorrhea; influenza-like

sx; asthenia; diarrhea;

impaired coordination;

insomnia; fever; tremor;

abdominal pain; dyspepsia;

pain; depression; vaginitis;

emotional lability; anorexia;

anxiety; irritability;

pharyngolaryngeal pain;

seizures; speech disturbance;

visual disturbance; UTI;

impaired concentration;

constipation; hot flashes;

neck pain; nystagmus;

photosensitivity; xerostomia;

amenorrhea; edema;

lymphadenopathy

Treatme

nt of

dementia

-related

mood

changes

! 12

Student Name: Keri Bennett

Levoflo

xin

Oral

750

Q48

Subclass:

Bioterrorism;

H. pylori;

Tuberculosis

(TB);

Fluoroquinolon

Mechanism of

Action

bactericidal;

inhibits DNA

gyrase and

topoisomerase

hypersens. to drug/class/

compon.; myasthenia

gravis; QT prolongation;

electrolyte abnormalities,

uncorrected; caution if

congenital long QT

syndrome; caution if QT

prolongation family hx;

caution if torsades de

pointes hx; caution if

ventricular arrhythmias;

caution if bradycardia;

caution if recent MI;

caution if CHF; caution in

pediatric pts; caution in

pts >60 yo; caution if

kidney, heart or lung

transplant; caution if

tendon disorder hx;

caution if peripheral

neuropathy or hx; caution

if renal impairment;

caution if CNS disorder;

caution if seizure

disordes; caution if

seizure threshold lowered;

caution if diabetes

mellitus; caution if

dehydration; caution if

recent abx-assoc. colitis

hx; caution if depression

or hx

Serious Reactions

anaphylaxis; hypersensitivity

rxn; phototoxicity; C.

difficile-assoc. diarrhea;

superinfection; ICP incr.;

seizures; toxic psychosis;

depression; suicidality; QT

prolongation; torsades de

pointes; skin rxn, severe;

vasculitis; pneumonitis,

hypersensitivity; serum

sickness; nephrotoxicity;

hepatotoxicity;

myelosuppression; blood

dyscrasias; peripheral

neuropathy; tendon rupture;

arthralgia/myalgia;

arthropathy (animal studies);

myasthenia gravis

exacerbation; uveitis

Common Reactions

nausea; headache; diarrhea;

insomnia; constipation;

dizziness; abdominal pain;

vomiting; dyspepsia;

tendinitis; anxiety; agitation;

confusion

Treatme

nt of

bacterial

commun

ity-

acquired

pneumon

Nystatin

100,000

unit/mL

Topic

Topi

cal

pow

der

TID

Antifungals;

Candidiasis,

Oropharyngeal/

binds to cell

membrane

sterols,

increasing

permeability

hypersens. to

drug/class/

components

Serious Reactions:

hypersensitivity reaction

Common Reactions:

nausea vomiting, diarrhea,

abdominal pain

Treatme

nt of

candidia

sis

! 13

Student Name: Keri Bennett

Klor-

Con 10

(Potassi

chloride

)

Oral

10m

daily

Subclass:

Electrolytes

Mechanism of

Action:

replaces

potassium, a

major

intracellular

cation involved

in physiologic

processes such

as nerve

impulse

conduction,

cardiac,

skeletal, and

smooth muscle

contraction, and

maintaining

normal renal

fxn

hypersens. to drug/class/

compon.; hypersens. to

corn (dextrose-containing

IV forms); hyperkalemia;

delayed GI transit (solid

dose forms); esophageal

stricture (solid dose

forms); GI obstruction

(solid dose forms); renal

failure (IV use); caution if

renal impairment; caution

if cardiovascular dz;

caution if adrenal

insufficiency; caution if

acidosis; caution if

dehydration; caution if

extensive tissue

breakdown; caution if K-

aggravated skeletal

muscle channelopathies

Serious Reactions

hyperkalemia; arrhythmias;

GI obstruction; GI bleeding;

GI perforation/ulcer;

hypersensitivity rxn

(dextrose-containing IV

forms); anaphylaxis

(dextrose-containing IV

forms)

Common Reactions

nausea; vomiting; flatulence;

abdominal discomfort/pain;

diarrhea; hyperkalemia

Nutrition

supplem

ent

Rozere

Oral

8mg

daily

2000

hour

Subclass:

Insomnia

Mechanism of

Action:

binds to

melatonin MT1

and MT2

receptors,

inducing sleep

(melatonin

receptor

agonist)

hypersens. to drug/class/

compon.; sleep apnea,

severe; hepatic

impairment, severe;

caution if hepatic

impairment, mild-

moderate; caution if

smoking habit changes;

caution if depression;

caution if COPD, severe

Serious Reactions

suicidal ideation; depression

exacerbation; behavioral

disturbance; hallucinations;

complex sleep-related

behavior; anaphylaxis/

anaphylactoid rxn; hepatic

tumors (animal studies)

Common Reactions

headache; somnolence;

fatigue; dizziness; nausea;

insomnia; URI; diarrhea;

arthralgia/myalgia;

depression; taste changes;

prolactin elevated;

testosterone decr.; cortisol

decr.

Sleep aid

! 14

Student Name: Keri Bennett

Rispend

one

Oral

1mg

ever

morn

ing

and

2mg

bedti

Subclass:

Tourette

Syndrome/Tic

Disorders;

Bipolar

Disorder;

Antipsychotics,

2nd generation

Mechanism of

Action:

exact

mechanism of

action

unknown;

antagonizes

dopamine D2

receptors,

serotonin 5-

HT2 receptors,

others

hypersens. to drug/class/

compon.; hypersens. to

paliperidone; caution in

pediatric or adolescent

pts; caution if pregnancy

3rd trimester; caution in

elderly pts; caution if

dementia-related

psychosis; caution if renal

impairment; caution if

hepatic impairment;

caution if Parkinson dz;

caution if neuroleptic

malignant syndrome hx;

caution if seizure hx;

caution if cardiovascular

dz; caution if

cerebrovascular dz;

caution if hypotension;

caution if hypovolemia;

caution if dehydration;

caution if high

environmental

temperature; caution if

aspiration pneumonia

risk; caution if PKU

(phenylalanine-containing

forms); caution if diabetes

mellitus; caution if

diabetes mellitus risk;

caution if drug-induced

leukopenia or neutropenia

hx; caution if leukopenia

or neutropenia; caution if

suicide risk

Serious Reactions

hypotension, severe;

syncope; extrapyramidal sx,

severe; tardive dyskinesia;

neuroleptic malignant

syndrome; hyperglycemia;

diabetes mellitus; seizures;

priapism; stroke; TIA;

dysphagia, severe;

hypersensitivity rxn;

angioedema; anaphylaxis;

erythema multiforme;

leukopenia; neutropenia;

agranulocytosis; suicidality;

hypothermia; hyperthermia

Common Reactions

somnolence; appetite incr.;

fatigue; insomnia; rhinitis;

URI; nausea/vomiting;

cough; urinary incontinence;

sialorrhea; constipation;

fever; extrapyramidal sx;

dystonia; abdominal pain;

anxiety; dizziness; headache;

xerostomia; tremor; rash;

akathisia; dyspepsia;

tachycardia; weight gain;

visual disturbance;

hyperprolactinemia;

confusion; gynecomastia;

photosensitivity; epistaxis;

dyslipidemia; impaired body

temperature regulation

Treatme

nt of

dementia

-related

confusio

n and

psychosi

! 15

Student Name: Keri Bennett

Xanelto

(Rivaro

xaban)

Oral

15m

daily

Subclass:

Anticoagulants

Mechanism of

Action:

selectively

blocks active

site of factor

Xa, inhibiting

blood

coagulation

(factor Xa

inhibitor)

hypersens. to drug/class/

compon.; active major

bleeding; hepatic

impairment, Child-Pugh

Class B or C;

coagulopathy-assoc.

hepatic dz; CrCl <30

(DVT prophylaxis,

recurrent DVT/PE

prophylaxis, DVT/PE tx

use); acute PE w/

hemodynamic instability;

acute PE requiring

thrombolysis; acute PE

requiring pulmonary

embolectomy; pregnancy;

caution if CrCl 30-50

(DVT prophylaxis use);

caution if CrCl 15-50

(thromboembolism/stroke

prophylaxis use); caution

in elderly pts; caution if

bleeding risk; caution if

epidural or spinal

anesthesia; caution if

spinal puncture; caution if

prosthetic heart valve

Serious Reactions

bleeding, severe; epidural/

spinal hematoma;

thrombocytopenia;

agranulocytosis;

hypersensitivity rxn;

Stevens-Johnson syndrome;

hepatitis

Common Reactions

bleeding; back pain; pruritus;

ALT elevated; platelets decr.

Preventi

on of

blood

clots

secondar

y to

chronic

a. fib.

Vacyclo

vir HCl

Oral

1000

daily

Subclass:

Herpes/

Varicella/Zoster

(HSV/VZV)

Mechanism of

Action:

inhibits DNA

polymerase;

incorporates

into viral DNA

hypersens. to drug/class/

compon.; caution if

immunocompromised;

caution if advanced HIV

dz; caution if renal

impairment; caution if

concurrent nephrotoxic

agent use; caution in

elderly pts; caution if

dehydration

Serious Reactions

acute renal failure;

thrombocytopenia; aplastic

anemia; anaphylaxis; TTP;

hemolytic-uremic syndrome;

erythema multiforme;

delirium; aggressive

behavior; psychosis;

encephalopathy; seizures

Common Reactions

nausea; headache; vomiting;

dizziness; abdominal pain;

dysmenorrhea; arthralgia;

depression; neutrophils decr.;

ALT, AST elevated; fatigue;

rash; alk phos elevated;

platelets decr.;

photosensitivity; diarrhea

(peds pts); fever (peds pts)

Treatme

nt of

viral

infection

! 16

Student Name: Keri Bennett

Ibuprofi

Oral

650

Q6H

exact

mechanism of

action

unknown;

inhibits

cyclooxygenase

, reducing

prostaglandin

and

thromboxane

synthesis

hypersens. to drug/class/

compon.; ASA or NSAID-

induced asthma or

urticaria; aspirin triad;

pregnancy starting at 30

wk gestation; CABG

surgery periop use;

caution if recent MI;

caution if stroke hx;

caution if cardiovascular

dz; caution if cardiac dz

risk; caution if HTN;

caution if CHF; caution if

fluid retention; caution if

dehydration; caution if

PUD; caution if GI

bleeding hx; caution if

coagulation disorder;

caution if chronic alcohol

use; caution if smoker;

caution in elderly pts;

caution in debilitated pts;

caution if hepatic

impairment; caution if

renal impairment; caution

if asthma; caution if

prolonged use; caution in

female pts trying to

conceive

Serious Reactions

GI bleeding; GI perforation/

ulcer; MI; stroke;

thromboembolism; HTN;

CHF; renal papillary

necrosis; nephrotoxicity;

hepatotoxicity; anaphylaxis/

anaphylactoid rxn;

bronchospasm; exfoliative

dermatitis; Stevens-Johnson

syndrome; toxic epidermal

necrolysis;

thrombocytopenia;

agranulocytosis; aplastic

anemia; anemia, hemolytic;

neutropenia; pancytopenia;

headache exacerbation (use

>10 days/mo)

Common Reactions

dyspepsia; nausea;

abdominal pain; constipation;

headache; dizziness;

drowsiness; rash; ALT, AST

elevated; fluid retention;

tinnitus; ecchymosis;

photosensitivity; delayed

ovulation

Treatme

nt of

mild to

moderate

pain and

inflamm

ation

Guafene

sin

Oral

5ml

syru

Q4H

Subclass:

Expectorants

Mechanism of

Action:

increases

volume and

decreases

viscosity of

respiratory tract

secretions

hypersens. to drug/class/

compon., caution if

nephrolithiasis, caution in

pts <6 yo

Serious Reactions

nephrolithiasis

Common Reactions

rash, vomiting, nausea

Thin and

expel

mucus

secretion

s of

lungs

! 17

Student Name: Keri Bennett

(Provent

il HFA)

Albuter

Nebu

lizer

puffs

Q4H

selectively

stimulates

beta-2

adrenergic

receptors,

relaxing airway

smooth muscle

severe hypersens. to milk

protein (DPI form);

caution if MAO inhibitor

use w/in 14 days; caution

if TCA use w/in 14 days;

caution if ischemic heart

dz; caution if HTN;

caution if arrhythmias;

caution if hypokalemia;

caution if diabetes

mellitus; caution if seizure

disorder; caution if

hyperthyroidism; caution

if unusually responsive to

sympathomimetic amines;

caution in labor and

delivery; caution if renal

impairment (high dose

use)

Serious Reactions

bronchospasm, paradoxical;

anaphylaxis; hypersensitivity

rxn; HTN; hypotension;

angina; cardiac arrest;

arrhythmia; hypokalemia;

hyperglycemia

Common Reactions

throat irritation; URI sx;

cough; bad taste; tremo;

dizziness; nervousness;

nausea/vomiting; headache;

palpitations; tachycardia;

pain; hyperlactatemia

Increases

breathin

g ease by

opening

bronchio

les to

increase

airflow

Miralax

Oral

1pkg

daily

Subclass:

Constipation 3:

Osmotic

Laxatives

Mechanism of

Action: causes

water retention

in stool,

producing

laxative effect

hypersens. to drug/class/

compon.; GI obstruction,

known or suspected;

caution in elderly pts

Serious Reactions

electrolyte disorders

(prolonged or excessive use);

laxative dependence

(prolonged or excessive use)

Common Reactions

nausea; abdominal

distension; cramping;

flatulence; diarrhea; urticaria

Preventi

on and

relief of

constipat

ion

! 18

Student Name: Keri Bennett

V. Top Three Prioritized Medical and Nursing Diagnosis

1. Sepsis: (actual) impaired respiration r/t pneumonia AEB O2 saturation of 91%,

tachycardia, productive cough, and x-ray consistent with pneumonia.

2. Sepsis: (actual) infection r/t pneumonia AEB elevated WBC count, fever of 101.8*F,

positive blood cultures, x-rays consistent with pneumonia-like findings.

3. Sepsis: (actual) dementia r/t dementia AEB patient is a poor historian, patient is

accompanied by personal aide, patient is on dementia medication, patient is not oriented to place

or time.

Care Plan

Medical &

Nursing Dx

Nursing

Outcomes

(NOC)

Nursing Interventions (NIC)

Evaluation

1. Sepsis:

(actual)

impaired

respiration r/t

pneumonia

AEB O2

saturation of

91%,

tachycardia,

productive

cough, and x-

ray consistent

with

pneumonia.

1A. During

the nurse’s 8

hour shift, the

patient will

remain

afebrile.

1B. During

the nurse’s 8

hour shift, the

patient will

maintain or

improve

airway

clearance.

1C. During

the nurse’s 8

hour shift, the

patient will

not develop

any blood

clots.

1A-1. The nurse will encourage the patient to drink

adequate fluids consistent with her RDI as

established by her body weight.

1A-2. The nurse will administer antibiotics as

prescribed to combat the bacterial infection causing

fever.

1A-3. The nurse will administer expectorant drugs as

prescribed in order to loosen and thin respiratory

mucus secretions so that the patient can expel them

from her lungs.

1B-1. The nurse will encourage the patient to engage

in deep breathing exercises every hour to open and

maintain airways.

1B-2. The nurse will monitor the patient at

mealtimes, and assist in feeding if necessary to

prevent aspiration.

1B-3. The nurse will be prepared to administer O2 if

necessary if the patient’s oxygen saturation dips

below an acceptable level.

1C-1. The nurse will assist and encourage the patient

to ambulate as tolerated to increase the circulation to

her extremities.

1C-2. The nurse will follow DVT prophylaxis

protocol as per hospital policy with the application of

compression stockings, etc.

1C-3. The nurse will administer Xanthol as

prescribed to prevent blood clots.

1A. During the

nurse’s 8 hour

shift, the

patient

remained

afebrile with a

temperature

less than

100*F.

1B. During the

nurse’s 8 hour

shift, the

patient

engaged in

incintence

spectrometry

and verbalized

that they felt

their airway

clearance had

improved.

1C. During the

nurse’s 8 hour

shift, the

patient did not

develop any

blood clots.

! 19

Student Name: Keri Bennett

Pathophysiology

!Mrs. H is a 89 year old Caucasian female who presented to Lynchburg

Emergency Department on 2/01/2018. She had visited the ED the previous day for

pneumonia-like symptoms. X-rays done at that time were consisted with pneumonia

findings and Levaquin was administered. After refusing further treatment or testing,

Mrs. H was released to her home. On 2/01 she was transported back to the ED via

EMS services for altered mental status. Mrs. H was accompanied by a CNA who cares

for her at Westminster Canterbury; due to Mrs. H’s confused state, all medical history is

courtesy of her aide. Per her aide, no fever, chills, or unusual shortness of breath have

been noticed. Mrs. H does have a moderate cough, which produces small amounts of

whitish/yellowish sputum. The patient denies any headache, chest pain, or blurred

vision."

!Initial examination findings indicated that Mrs. H was significantly febrile

(101.7*F), tachypnic (22bpm) and suﬀering from poor oxygen perfusion (91% oxygen

saturation). She was admitted to the pulmonary unit of LGH for further evaluation and

treatment of suspected pneumonia and septic infection. The following is a discussion

of the pathophysiology of her pneumonia and sepsis diagnosis, as well as the rationale

behind her treatment strategies."

!Pneumonia is an infection of the lungs that occurs when pathogenic invaders

enter the alveoli and overcome the immune defenses, colonizing and triggering an

inflammatory response causing in the alveoli to fill with fluid. Although pneumonia can

be caused by a number of factors: bacteria, viral, or protozoan, because Mrs. H’s

infection is believed to be bacterial in nature, our focus will remain primarily on this

source. "

! 20

Student Name: Keri Bennett

!Because of the multi-faced nature of immunity, in order for a pneumonia

infection to occur, several branches of the immune system must be breached (Ackley,

2017). One of the first and most important lines of defense in the reparatory tract is the

mucoid secretions produced by the pulmonary goblet cells (Porth, 2011). Mucus

prevents bacterial growth in two ways. First, it physically traps the invading pathogens

before they reach the delicate lung tissues, and second, the naturally basic pH of

mucus discourages bacterial growth (Seeley, 2016). Although the high pH of mucus

prevents much pathogenic growth, it is possible for some bacteria to take up residence

within it. Staphylococci, for instance, are capable of surviving in a wide range of acidic

and basic environments and are responsible for the majority of factorial pneumonias

(Batzing, 2012). Normal pH values in tracheal mucus range from 6.9–9.0, but infection

can lower pH values to as low as 5.8. The viscosity of mucus increases with acidity,

making it more diﬃcult to expel from respiratory passages (Porth, 2013)."

!Pulmonary secretions containing trapped bacteria must constantly be moved to

the top of the trachea and excreted. One of the ways in which mucus is moved is via

the cilia. These hair-like structures move in wave-form to locomote mucoid secretions

out of the lungs and into the esophagus for elimination. If the cilia are damaged via

smoke consumption, genetic disorders, or medication, there is stasis of fluid and the

risk for infection is increased (Seeley, 2016). Additionally, significantly lowered ciliary

beating function is observed below pH 7.0 for bronchi and below pH 5.0 for

bronchioles. These changes in pH, while not permanently damaging to the cilia, impair

mucocillary clearance even further and play a significant role in the development of

pneumonia (Linares, 2011). While the sticky consistency of mucus is beneficial in that it

traps mucus during breathing and prevents it from reaching the lungs, in the event of

mucoid stasis, it can act as a medium for pathogens to take up residence and colonize

! 21

Student Name: Keri Bennett

(Porth, 2013). Mrs. H is prescribed Guaifenesin, an expectorant that works by reducing

the viscosity of pulmonary secretions. Thus, the ciliary actions are more eﬀective and

the eﬃciency of the cough reflex is improved, allowing secretions to be removed

(Skidmore-Roth, 2018)."

!Another way in which mucoid secretions are moved through the respiratory tract

is by breathing. The movement of air fills the lowest alveoli sacs, displacing mucus and

also assisting the ciliary elevator in moving mucus out of the respiratory tract. Opening

the alveolar sacs not only helps with the prevention of fluid stasis, it also is important to

ensure adequate blood flow, lung elasticity, and oxygen delivery, a well as the

prevention of inflammatory reactions which could further cause respiratory issues

(Ackley, 2017). When the sacs are closed, blood flow is decreased, potentially could

leading to tissue necrosis, and resulting in a lack of immune cells delivered to the

tissue. Because the majority of initial immune modulators are transported in the blood,

it is vital that blood reach all areas of the body to precipitate the removal and

destruction of pathogenic material (Remick, 2017)."

!Mrs. H has been prescribed nebulizer albuterol treatments to relax the smooth

muscle of the airway and dilate bronchioles, allowing for increased air circulation in the

lower parts of the lungs. Bronchial smooth muscle is innervated by beta2-adrenergic

receptors, the stimulation of which activates Gs adenylyl cyclase cyclic AMP pathway

resulting in smooth muscle tone reduction. Albuterol also leads to smooth muscle

membrane hyperpolerization and relaxation by acting as a smooth muscle by

increasing the conductance of calcium and potassium channels, possibly by the

regulation of capacitative calcium ion entry by small G proteins. Albuterol may also

exert an influence on the function of mast, cells, basophils, eosinophils, neutrophils,

! 22

Student Name: Keri Bennett

and lymphocytes by stimulating beta2-adrenergic receptors in these cell types,

increasing intracellular cyclic AMP thereby activating a signaling cascade that inhibits

the release of inflammatory mediators and cytokines (Brunton, 2006)."

!In the event that an infection does begin to take hold, the inflammatory response

is triggered. The inflammatory response is non-specific, meaning that it reacts

identically to all pathogenic processes, regardless of type or origin (Porth, 2013). The

inflammatory response is a complex process involving many cellular, molecular, and

systemic processes. When foreign pathogens penetrate the epithelium, cytokines are

released. Cytokines — the mediators of inflammation — trigger mast cells located in

the interstitial fluid. These mast cells induce capillary vasodilation by the release of

histamine, which acts on capillary receptors to induce collagenase-driven restructuring

of the vascular cytoskeleton and smooth muscle relaxation. The vasodilatory eﬀects of

histamine are responsible for swelling associated with inflammation, as the increased

porosity of the microvascular system allows blood-born immunity mediators and

plasma to accumulate in the extracellular space (Buckley, 2014). There are many

benefits to increased blood flow to the infection site: antibodies, nutrients, and oxygen

are delivered to help combat infection and repair damaged tissue, toxins are diluted,

and fibrin formation is increased. Histamine perpetuates this reaction by acting as a

positive feedback messenger, attracting more mast cells, as well as other leukocytes

and inflammatory mediators, to the site of infection (Rinewalt, 2014). "

Dendritic cells change to their phagocytosis form under the influence of

histamine and begin to envelop and digest damaged cells and bacteria. Dendritic cells

also release chemical messengers to activate helper T-lymhocytes and macrophages,

which then marginalize and initiate the specific immune response (Rosa, 2014).

! 23

Student Name: Keri Bennett

Macrophages induce collagenase secretion from karatinocytes and other macrophages

by the release of interleukin-1 (IL-1), which initiates cytoskeletal rearrangement, as well

as the proliferation and migration of CD4, CD8, and mature B-cells, immunoglobulin

secretion, and proliferation of fibroblasts (Buckley, 2014)."

!Blood plasma is also involved in the inflammatory response, as it contains small

proteins (compliment) created by the liver which function as a non-specific immune

response perpetuator. Compliment proteins act as cytokines as well as exhibiting a

bactericidal eﬀect on invading pathogens. The exact mechanism of initiation for

compliant proteins is unknown, but they are believed to be converted to their active

form by cleaving enzymes released from damaged cells or activated by inflammatory

paracrine signaling (Porth, 2013). "

!While the vascular nature of the lungs is beneficial in that it increases the

delivery of leucocytes and other immune mediators to the site of infection, increased

capillary permeability secondary to the inflammatory process also increases the risk

that bacteria will enter the bloodstream, resulting in a septic infection (Ackley, 2017).

Mrs. H’s septic infection is likely the result of pathogens from her lungs entering her

bloodstream. Her white blood cell count , although currently within normal limits, was

initially elevated at 11.3 x10^9/L. Her ANC was also initially elevated at 8,500/mm^3,

which is consistent with a pneumonial infection. "

!Sepsis is harmful to the body in two primary facets. First, bacteria traveling

through the bloodstream may colonize any organ or tissue in the body. Of primary

concern are meningeal infections, as well as infections of the heart, lungs, and the

tissue surrounding these organs. Secondly, infectious agents trigger the inflammatory

response wherever they are located in the body. While the inflammatory response is

! 24

Student Name: Keri Bennett

beneficial in localized infections, systemically, it can result in septic shock and death.

The inflammatory response decreases platelet counts, increases the risk of organ

damage (which further triggers inflammatory reactions), and may cause leukocytosis or

leukopenia (Remmick, 2017). Mrs. H is currently on a antibiotic regimen of levofloxin to

eliminate the bacteria causing her septic infection. Levofloxin. a quinolone, is

bactericidal to both Gram-positive and Gram-negative bacteria. It functions by

inhibiting the activity of DNA gyrase and topoisomerase IV, preventing the replication

and supercoiling of bacterial DNA, thus making survival of the invading organism

impossible (Skidmore-Roth, 2018). Mrs. H is responding well to antibiotic treatment;

her white blood cell count is currently within normal limits and she has been afebrile for

the last three days, indicating that the infection is being subdued. "

!Not only does the inflammatory response pose risks to the body’s circulatory

system, it also aﬀects glucose regulation by triggering glycolysis in the liver (Porth,

2017). During her admission, Mrs. H’s glucose levels have fluctuated significantly, with

levels between 48-176mg/dL. Although these levels are not critical, and her latest

glucose reading was an “acceptable high” of 104mg/dL, the fluctuating values are

indicative of poor systemic management of glucose and insulin needs, likely as a result

of infection-related stress (Ackley, 2017). Mrs. H has been able to manage her blood

sugar using dietary interventions, without the need of medicinal assistance, however,

many patients require insulin injections to prevent ketoacidosis, a life-threatening

condition in which the inflammatory response can trigger an insulin deficiency

preventing the uptake of glucose into the cells. Without glucose accessible for

degradation, the body is forced to metabolize triglycerides and muscle tissue for

energy. Lipolysis causes serum levels of glycerol and free fatty acids (FFA’s) to rise,

acting as a substrate for the liver to initiate the gluconeogenesis stimulated by the

! 25

Student Name: Keri Bennett

excess of glucagon released by glucose-starved cells. Glucagon also stimulates the

mitochondria to convert FFAs into ketones, acidic compounds which alter blood pH,

triggering metabolic acidosis (Rinewalt, 2014). "

!Mrs. H’s elevated blood glucose levels, while not critical, are concerning in that

they may slow the rate of healing from her septic infection. Bacteria thrive in a

glucose-rich environment, increasing their rate of proliferation. High serum glucose also

alters the viscosity of the blood, slowing its progress through the circulatory system

and impeding the delivery of phagocytotic leukocytes to invading pathogens and

nutrients necessary for cells to perform regrowth and repair functions. Additionally

elevated glucose levels impede the action of leukocytes by directly altering their

functionality. Some white blood cells are unable to survive in high-glucose solutions,

while others’ signaling mechanisms are impaired, decreasing their ability to respond to

and take action against invading organisms (Batzing, 2012). In this way, something as

apparently innocuous as elevated blood glucose levels can exponentially lengthen the

healing time for infections and injuries. "

!Pathogens typically reach the alveoli in overwhelming levels if there is an

infection which has colonized the upper airway, or in the event of aspiration. Studies

have indicated that in 18% of pneumonia cases, nasal colonies of staphylococci are

present (Batzing, 2012). Patients on aspiration precautions are times more likely to

contract pneumonia infections. Dementia negatively impacts an individual’s ability to

properly chew and swallow. Given Mrs. H’s dementia diagnosis, is likely that she could

have aspirated while eating, leading to pneumonia (Etgen, 2011). She is currently

prescribed Benztropine, Rispendone, and Lamictal for the management of her

dementia symptoms. Benztropine antagonizes acetylcholine and histamine receptors,

! 26

Student Name: Keri Bennett

combating the dystonia typical of dementia-related degeneration. Lamictal is used to

regulate mood changes by inhibiting voltage-dependent sodium channels, preventing

presynaptic glutamate and aspartate release and thus reducing membrane excitability.

Rispendone is thought to antagonize dopamine D2 receptors, and serotonin 5-HT2

receptors, thus regulating mood and preventing dementia-related psychosis

(Skidmore-Roth, 2018). Mrs. H is prone to sundowners’s syndrome, a phenomenon

common among dementia patients, in which her confusion significantly increases at

night. For this reason, she takes an increased dose of Rispendone in the evenings to

help combat these eﬀects (Erkinjuntti, 2017). "

!Because of the increased coagulation response of the blood during

inflammation, Mrs. H is at increased risk of thrombosis formation. She is already at risk

for blood clots as a result of ineﬀective blood movement through the upper chambers

of her heart secondary to her atrial fibrillation, and this, combined with the

compromised state of her cardiovascular system, may result in hyper-excitability of the

clotting cascade and increased thrombus formation, increasing her risk of pulmonary

embolism or stroke (Linares, 2011). Mrs. H is on Xanelto, a highly selective direct

Factor Xa inhibitor, to prevent the formation of blood clots through both the intrinic and

extrinsic pathways. Unlike Heparin, Xanelto has no eﬀects on Factor II or on platelets,

making its eﬀects easy to regulate and eliminating the need for diet modification while

taking the drug (Skidmore-Roth, 2018). Mrs. H continues to respond well to treatment

with Xanelto, and has not exhibited any signs of pulmonary emboli. "

!Overall, Mrs. H is responding well to treatment and is scheduled to return to her

home after her antibiotic course is completed. She will continue to take her normal

! 27

Student Name: Keri Bennett

dementia medications. Increased surveillance during mealtimes has been

recommended to reduce her risk of aspiration while eating. "

! 28

Student Name: Keri Bennett

References"

!Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook:

an evidence-based guide to planning care. St. Louis, MO: Elsevier."

Boston: McGraw-Hill."

!Batzing, B. L., & Chiras, D. D. (2012). Microbiology: an introduction. Australia:

Brooks/ Cole. %

!Brunton, LL, et al. (eds.). (2006). (Goodman & Gilman's) The Pharmacological

Basis of Therapeutics (11th Ed.). McGraw-Hill-Medical Publishing Division, New York,

NY. 720."

!Buckley, C. D., Gilroy, D. W., & Serhan, C. N. (2014). Pro-Resolving lipid

mediators and Mechanisms in the resolution of acute inflammation. Immunity, 40(3),

315–327. http://doi.org/ 10.1016/j.immuni.2014.02.009"

!Cernea, S., and Dobreanu, M. (2013). Diabetes and beta cell function: from

mechanisms to evaluation and clinical implications. Biochemia Medica, 23(3), 266–280.

http://doi.org/10.11613/BM.2013.033"

!Erkinjuntti, T. (1999). Cerebrovascular Dementia: Pathophysiology, Diagnosis and "

Treatment. CNS Drugs, 12(1), 35-48.%

!Etgen, T., Sander, D., Bickel, H., & Förstl, H. (2011). Mild Cognitive Impairment

and "

!Linares, H. A. (2011). Sepsis, Disseminated Intravascular Coagulation and

Multiorgan Failure: Catastrophic Events in Severe Burns. Shock, Sepsis, and Organ

Failure, 370-398. doi: 10.1007/978-3-642-76511-7_15 "

! 29

Student Name: Keri Bennett

!Porth, Carol. (2013). Essentials of pathophysiology: concepts of altered health

states. Philadelphia :Lippincott Williams & Wilkins"

!Remick, D. G. (2017). Pathophysiology of Sepsis. The American Journal of

Pathology, 170(5), 1435-1444. doi:10.2353/ajpath.2007.060872 "

!Rinewalt, D., & Velasco, J. M. (2014). Systemic Inflammatory Response

Syndrome (SIRS) and Sepsis. Common Surgical Diseases, 361-362. doi:

10.1007/978-1-4939-1565-1_91 "

!Rosa, A. C., & Fantozzi, R. (2013). The role of histamine in neurogenic

inflammation. British Journal of Pharmacology, 170(1), 38–45. http://doi.org/10.1111/

bph.12266 "

!Seeley, R. R., Stephens, T. D., & Tate, P. (2016). Essentials of anatomy and

physiology."

!Sheagren, J. N. (1989). Pathophysiology of Sepsis and Septic Shock. Sepsis,

23-34. doi: 10.1007/978-3-642-83083-9_4 "

!Skidmore-Roth, L. (2018). Mosbys 2018 nursing drug reference. St. Louis, MO:

Elsevier Mosby."

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