ORAL EXAM CASE REVIEWER

MULTIORGAN DYSFUNCTION

A. DESCRIPTION
● Multiple Organ Dysfunction Syndrome (MODS) can be defined as the development of potentially reversible physiologic derangement involving two or more
organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life-threatening physiologic insult.
● It is initiated by illness, injury or infection and most commonly affects the heart, lungs, liver and kidneys.

B. FOCUS ASSESSMENT (SIGNS AND SYMPTOMS)

ORGAN AFFECTED DESCRIPTION SIGNS AND SYMPTOMS

Lung/Respiratory ● Respiratory failure can happen as a result of ● Subjective:

injury, infection, or surgical complications. ○ Difficulty breathing
○ anxiety
 ● Objective:
○ Hypoxia
○ Tachypnea
○ Cyanosis

Heart/Cardiovascular ● Heart failure can occur when the heart muscle ● Subjective:
is too weak or stiff to pump blood properly. ○ Chest pain
● Heart failure can lead to both kidney and liver ○ Weakness
damage, as the blood flowing from the heart ● Objective:
to the kidneys may decrease, and the liver ○ Tachycardia
may experience pressure from fluid buildup. ○ Hypotension/Hypertension
○ Peripheral edema

Kidney/Renal ● Acute renal failure happens when the kidneys ● Subjective:

are not able to filter waste from the blood. ○ Nausea
When the kidneys lose this ability, dangerous ● Objective:
levels of waste can accumulate, and the ○ Oliguria
blood’s chemistry may become unbalanced ○ Peripheral edema
○ High creatinine
○ High BUN

Liver/Hepatic ● Liver failure occurs when large parts of the ● Subjective:

liver become damaged beyond repair and the ○ Nausea
liver can no longer function ○ Abdominal pain
● Objective:
○ Ascites
○ Jaundice
○ High bilirubin
○ High liver enzymes
○ Low albumin

Brain/Neurologic ● Because the brain controls the other systems ● Subjective:

of the body, neurological dysfunction can ○ Headache
take many forms. ● Objective:
● However, an altered state of consciousness is ○ Altered consciousness
a common manifestation of neurological ○ Confusion
failure associated with MODS. ○ Psychosis
Blood/Hematologic ● Bleeding in the gastrointestinal tract or breaks ● Objective:
in the skin is common when someone is ○ Anemia (Low Hgb, hct, RBC)
experiencing multiple organ failure. This can ○ Low platelets
be very difficult to control or stop. ○ Low protein C
○ High D-dimer
○ Petechiae
○ High WBC (if with infection)

C. DIAGNOSTIC AND LABORATORY TESTS

DIAGNOSTIC TESTS LABORATORY TESTS

1. Lumbar puncture ● When meningitis or encephalitis
is suspected, LP must be
performed on an urgent basis. In
patients with an acute fulminant
presentation, rapid onset of septic
shock, and severe impairment of
mental status, bacterial meningitis
must be ruled out by means of LP.
1. Complete blood cell (CBC) ● An adequate hemoglobin
count concentration is necessary to
ensure oxygen delivery in shock;
hemoglobin should be
maintained at a level of 8 g/dL

2. Acute-phase reactants and ● Acute-phase reactants and

platelets platelets usually increase at the
onset of any serious stress. With
persistent sepsis, the platelet
count will fall, and disseminated
intravascular coagulation (DIC)
may develop.

3. white blood cell (WBC) ● WBC count may predict the

existence of a bacterial infection.
In adults who are febrile, a WBC
count higher than 15,000/µL or a
neutrophil band count higher
than 1500/µL is associated with a

4. Serum lactate
5. Coagulation status:
a. prothrombin time (PT)
b. activated partial
thromboplastin time
(aPTT)
6. Urinalysis and a urine culture
7. Gram stain and culture
high likelihood of bacterial
infection.
● provides an assessment of tissue
hypoperfusion. Elevated serum
lactate indicates that significant
tissue hypoperfusion exists with
the shift from aerobic to
anaerobic metabolism. This
signals a worse degree of shock
and a higher mortality.
● should by assessed by measuring
the prothrombin time (PT) and
the activated partial
thromboplastin time (aPTT).
Patients with clinical evidence of
coagulopathy require additional
tests to detect the presence of
DIC.
● should be ordered for every
patient who is in a septic state.
Urinary infection is a common
source of sepsis, especially in
elderly individuals. Adults who
are febrile without localizing
symptoms or signs have a
10-15% incidence of occult
urinary tract infection (UTI).
● Should be obtained from sites of
potential infection. Generally, the
Gram stain is the only available
test for immediately
documenting the presence of
bacterial infection and guiding
the choice of initial antibiotic
therapy.
Criteria for Organ Dysfunction
SYSTEM MILD CRITERIA SEVERE CRITERIA

Central Nervous System ● Confusion ● Coma

Peripheral nervous system ● Mild sensory neuropathy ● Combined motor and sensory deficit

Respiratory ● Hypoxia or hypercarbia necessitating ● Acute respiratory distress syndrome (ARDS)

assisted ventilation for 3-5 days requiring positive end-expiratory pressure
(PEEP) >10 cm H2 O and fraction of
inspired oxygen (FI O2) < 0.5

Renal ● Oliguria (< 500 mL/day) or increasing ● Dialysis

creatinine (2-3 mg/dL)

Cardiovascular ● Decreased ejection fraction with persistent ● Hyperdynamic state not responsive to
capillary leak pressors

Hepatic ● Bilirubin 2-3 mg/dL or other liver function ● Jaundice with bilirubin 8-10 mg/dL
tests >2 × normal, prothrombin time (PT)
elevated to 2 × normal

Gastrointestinal ● Intolerance of gastric feeding for more than 5 ● Stress ulceration with need for transfusion,
days acalculous cholecystitis

Hematology ● activated partial thromboplastin time ● disseminated intravascular coagulation

(aPTT) >125% of normal, platelets < (DIC)
50-80,000

D. RISK FACTORS
Modifiable Non-modifiable
 1. Infection 1. Age
2. Injury
3. Hypoperfusion
4. Hypermetabolism
5. A continuum of severity from sepsis to septic shock
and MODS exists

E. PATHOPHYSIOLOGY
https://drive.google.com/file/d/1Sv07tuC60soeXRn_t7hbW3XAYS1sXmjh/view?usp=sharing
F. NURSING DIAGNOSES (BY PRIORITY - 5)
1. Impaired gas exchange related to alveolar damage as manifested by difficulty of breathing
 2. Decreased Cardiac Output related to altered myocardial contractility as evidenced by tachycardia and hypertension
3. Ineffective tissue perfusion related to insufficient arterial blood flow as manifested by chest pain (also manifestations of brain, kidney, liver dysfunctions)
4. Activity Intolerance related to imbalance between oxygen supply and demand
5. Fear/Anxiety related to threat to health

G. NURSING CARE PLAN (3 PRIORITY PROBLEM)

NCP 1 (ACTUAL PROBLEM)

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Impaired gas Plaque formation SHORT TERM NIC: Respiratory Monitoring NOC: Respiratory
> Patient verbalized exchange related ↓ Within 1-2 Status: Ventilation
Atherosclerosis
“Grabe ang to alveolar ↓ hours of nursing INDEPENDENT
pananakit ng dibdib damage as Thromboembolism interventions, SHORT TERM
ko at kinakapos ako manifested by formation the patient will 1. Monitor patient’s 1. To evaluate the After 1-2 hours of
ng hininga. difficulty of ↓ be able to: respiratory rate, O2 sat effectiveness of nursing interventions,
Coronary Artery and ABGs. Auscultate interventions given and
Objective breathing Disease
● Demonstrate the patient was able
> RR: 28 bpm an patient’s breath sounds to monitor if there are to:
↓
> O2 sat: 80% Myocardial ischemia improvemen and evaluate progressive further alterations in ● Demonstrate an
> (+) Angina Pectoris ↓ t in shortness of breath and respiration that needs improvement in
> (+) DOB Heart pumps more respiratory level of consciousness. immediate interventions. respiratory pattern
↓
> (+) SOB Myocardial stress pattern as as evidenced by
> (+) Clubbing of ↓ evidenced decrease in RR
nails Left ventricular by decrease 2. Position patient in a 2. To promote maximum lung and increase in O2
> (+) Pallor dysfunction in RR and semi-fowler’s to high expansion and improve sat.
↓
increase in fowler’s position ventilation. ● Verbalize relief
Blood backs up in the
lungs O2 sat. from chest pain.
↓ ● Verbalize
Fluid is pushed in the 3. Maintain a calm attitude
relief from 3. To improve ventilation and
alveoli and assist the client to
chest pain. prevent anxiety and fear of the LONG TERM
↓ “take control” by using
Pulmonary edema patient that can heighten Within 2-3 days of
slower, deeper
↓ LONG TERM difficulty of breathing nursing interventions,
respirations”
Impaired gas exchange Within 2-3 days the patient will be able
Other Cause of nursing to:
(Pneumonia) 4. Teach and encourage the 4. To help the patient relax
interventions, ● Establish a normal
Immunocompromised patient to use and improve oxygenation.
↓ the patient will and effective
diaphragmatic breathing. This type of breathing also
Aspiration of be able to: respiratory pattern
can help decrease heart rate
nasopharyngeal bacteria ● Establish a and dilate blood vessels and with RR at 12-20
↓ normal and reduce the overall blood bpm, O2 Sat of
Microorganisms invades
airway and lungs effective pressure 95% above with
↓ respiratory relief of chest
Inflammatory response pattern with 5. To prevent worsening of pain, DOB, SOB,
↓ RR at 12-20 5. Encourage frequent rest shortness of breath because and no pallor, and
Accumulation of periods and teach the extra activity can aggravate
neutrophils and plasma
bpm, O2 Sat clubbing of nails.
exudates from of 95% patient to pace activity. shortness of breath.
capillaries into alveoli above with
↓ relief of
Inflammation of the chest pain, 6. Encourage 6. To prevent crowding of the
lungs small
DOB, SOB, diaphragm
↓ frequent meals.
Community Acquired and no
Pneumonia pallor, and
↓ clubbing of 7. Help the patient with 7. To conserve energy and
Further lung damage
nails. avoid overexertion and
↓ ADLs as necessary
fatigue.
Impaired Gas Exchange
DEPENDENT

1. To increase oxygen
supply, reduce shortness
1. Provide supplemental
of breath and ease the
oxygen as needed.
workload of the heart
and lungs.

2. To decrease the pressure of

2. Administer diuretics as
excess fluid in the heart and
prescribed.
lungs.

3. To open up bronchial tubes.

Albuterol has been reported to
3. Administer
help clear pulmonary edema
bronchodilators as
fluid from the alveolus by
prescribed.
accelerating the resorption of
alveolar fluid.

COLLABORATIVE

1. Collaborate with the 1. To evaluate lung function

 other healthcare teams in and detect acid-base
checking patient’s imbalance.
laboratory data and
imaging tests (ABGs and
CXR)

NCP 2 (RISK DIAGNOSIS)

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Decreased Occlusion in the SHORT TERM NIC: Hemodynamic Regulations NOC: Cardiac Pump
> Palpitations Cardiac Output artery Within 1-2 Effectiveness
> Fatigue related to altered ↓ hours of nursing INDEPENDENT SHORT TERM
> Feeling breathless Decreased blood interventions, After 1-2 hours of
myocardial Assess for jugular venous
> Anxiety supply the patient will nursing interventions,
Objective contractility as ↓ be able to: distention, extra heart sounds These are indicators of the patient was able
> Tachycardia evidenced by Decreased venous ● exhibits such as S3, changes in decreased cardiac output, to:
> Hypertension tachycardia and return warm, dry mental status or level of which should be reported ● exhibits warm, dry
> Peripheral edema hypertension ↓ skin, eupnea consciousness, cool promptly for timely skin, eupnea with
> Cyanosis Decreased amount with extremities, hypotension, intervention. absence of
of blood expelled absence of tachycardia, and tachypnea. pulmonary
by ventricles pulmonary crackles.
↓ crackles. Dyspnea, crackles, and ● remains free of
Decreased cardiac ● remains free shortness of breath signal side effects from
output of side fluid accumulation in the the medications
Assess lungs for adventitious
effects from lungs and may be a direct used to achieve
breath sounds and shortness
the indicator of ventricular adequate cardiac
of breath.
medications failure and decreased cardiac output.
used to output. Cardiac output
achieve decreases as HF progresses.
adequate
Decreasing urine output and
cardiac LONG TERM
weight gain can occur as a
output. After 24 hours of
Monitor I&O; weigh the result of decreased cardiac
nursing interventions,
patient daily. contractility, which can
LONG TERM the patient was able
cause decreased renal
Within 24 hours to:
perfusion and fluid retention.
of nursing ● demonstrates
interventions, adequate cardiac
Assist the patient into a This position decreases work
the patient will position of comfort, usually of breathing and reduces output as
be able to: semi-Fowler’s position cardiac workload. evidenced by
● demonstrate (HOB up 30-45 degrees). blood pressure and
s adequate pulse rate and
cardiac Schedule activities and rhythm within
To maximize rest periods.
output as assessments normal parameters
evidenced for patient; strong
by blood DEPENDENT peripheral pulses;
pressure and and an ability to
pulse rate ● Beta-blockers tolerate activity
and rhythm (metoprolol XL) and without symptoms
within alpha/beta-adrenergic of dyspnea,
normal blockers (carvedilol): syncope, or chest
parameters Block effects of SNS and pain.
for patient; toxic effects of
strong neurohormones on the
peripheral myocardium. These
pulses; and medications decrease HR
an ability to and BP, thereby
tolerate decreasing cardiac
activity workload.
without ● Calcium channel
Administer medications as
symptoms blockers: May be used in
prescribed, such as
of dyspnea, diastolic HF to assist
beta-blockers, calcium
syncope, or with relaxation and
channel blockers, and
chest pain. filling and reduce
antidysrhythmic agents.
outflow tract obstruction
(hypertrophic
cardiomyopathy). Except
for amlodipine or
felodipine, calcium
channel blockers are
avoided in LV systolic
dysfunction because they
decrease cardiac
contractility.
● Amiodarone is an
example of an
antidysrhythmic given
 for patients with HF.

Administer high-flow
To increase oxygen available
oxygen via mask or
for cardiac function
ventilator, as indicated

COLLABORATIVE

These tests can help indicate

the underlying cause of
decreased cardiac output.
EKG can reveal previous MI
or left ventricular
hypertrophy, indicating
aortic stenosis or chronic
Review results of EKG and
systemic hypertension. A
chest X-ray.
chest x-ray may provide
information on pulmonary
edema, pleural effusions, or
enlarged cardiac silhouette
found in dilated
cardiomyopathy or large
pericardial effusion.

The patient may be receiving

cardiac glycosides, and the
Examine laboratory data,
potential for toxicity is
especially arterial blood
greater with hypokalemia;
gases and electrolytes,
hypokalemia is common in
including potassium.
heart patients because of
diuretic use.

NCP 3 (READINESS/DISCHARGE DIAG)

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Ineffective tissue Decreased cardiac SHORT TERM NIC: —Circulatory Care: Arterial Insufficiency NOC: Tissue
> Chest pain perfusion related output Within 1-2 Perfusion: Peripheral
INDEPENDENT
> Headache to insufficient ↓ hours of nursing Helps differentiate type of SHORT TERM
> Nausea arterial blood Decreased preload interventions, problem (e.g., deep redness After 24 hours of
> Abdominal pain flow as and stroke volume the patient will in both hands triggered by nursing interventions,
Compare skin temperature
Objective ↓ be able to: vibrating machinery is the patient was able
manifested by and color with other limb
> Oliguria Decreased blood ● Verbalize associated with Raynaud’s, to:
chest pain (also when assessing extremity
> Peripheral edema pumped out from understandi while edema, redness, ● Verbalize
manifestations of circulation
> Altered the heart ng of swelling in calf of one leg is understanding of
consciousness brain, kidney, ↓ condition, associated with localized condition, therapy
> Confusion liver Decreased therapy thrombophlebitis). regimen, side
dysfunctions) perfusion regimen, effects of
throughout the body side effects Assess presence, location, medications, and
↓ of and degree of swelling or Useful in identifying or when to contact
Ineffective tissue medications, edema formation. Measure quantifying edema in healthcare
perfusion and when to circumference of extremities, involved extremity. provider.
contact noting differences in size. ● Demonstrate
healthcare behaviors and
provider. Protein-energy malnutrition lifestyle changes
● Demonstrate and weight loss make to improve
behaviors ischemic tissues more prone circulation (e.g.,
Note client’s nutritional and
and lifestyle to breakdown. Dehydration engage in regular
fluid status.
changes to reduces blood volume and exercise, cessation
improve compromises peripheral of smoking,
circulation circulation. weight reduction,
(e.g., engage disease
in regular Promotes collateral management).
exercise, circulation which promotes
cessation of Provide passive ROM proper carriage of blood
smoking, from small arteries, causing LONG TERM
weight them to open up. After 24 hours of
reduction, nursing interventions,
Position patients properly in Upright positioning promotes
disease the patient was able
a semi-Fowler’s to improved alveolar gas
management to:
high-Fowler’s as tolerated. exchange.
). ● Demonstrate
increased
DEPENDENT
perfusion as
LONG TERM individually
Within 24 hours Administer medications such To improve tissue perfusion appropriate (e.g.,
of nursing as antiplatelet agents,
or organ function. skin warm and dry,
interventions, thrombolytics, antibiotics peripheral pulses
 the patient will Administer fluids, To promote optimal blood present and strong,
be able to: electrolytes, nutrients, and flow, organ perfusion, and absence of edema,
● Demonstrate oxygen, as indicated. function. free of pain or
increased discomfort).
perfusion as COLLABORATIVE
individually
appropriate Review laboratory studies
(e.g., skin such as lipid profile,
warm and coagulation studies,
dry, hemoglobin/hematocrit,
peripheral renal/cardiac function tests,
pulses inflammatory markers (e.g.,
present and D dimer, C-reactive protein); To determine probability,
strong, and diagnostic studies (e.g., location, and degree of
absence of Doppler ultrasound, impairment.
edema, free magnetic resonance
of pain or angiography, venogram,
discomfort). contrast angiography, resting
ankle-brachial index [ABI],
leg segmental arterial
pressure measurements)

In-depth wound care may

include debridement and
Refer to wound care
various specialized dressings
specialist if arterial or
that provide optimal
venous ulcerations are
moisture for healing,
present
prevention of infection and
further injury.

H. NURSING MANAGEMENT/INTERVENTION (Angel)

● All invasive procedures must be carried out with aseptic technique after careful hand hygiene.
○ Rationale: For infection control
● Assess patient’s hemodynamic status, vital signs, GCS, fluid intake and output, and nutritional status
○ To have a baseline data and be able to monitor patient’s condition
● Administer oxygen along with medication therapy
○ Rationale: To assist with relief of symptoms.
● Removal of secretions
 ○ Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery.
● Adequate hydration of 2 to 3 liters per day
○ To loosen pulmonary secretions.
● Teach coughing exercises
○ An effective, directed cough can also improve airway patency.
● Perform chest physiotherapy
○ To loosens and mobilizes secretions.
● Encourage bed rest with the back rest elevated
○ Rationale: to help decrease chest discomfort and dyspnea.
● Encourage changing of positions frequently
○ Rationale: To help keep fluid from pooling in the bases of the lungs.
● Check skin temperature and peripheral pulses frequently
○ To monitor tissue perfusion
● Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in
skin color, and laboratory values.
○ To be able to report and provide immediate interventions as needed.
● Discuss glucose monitoring at home with the patient according to individual parameters.
○ To identify and manage glucose variations.
● Discuss how client’s antidiabetic medications work.
○ Educate client on the functions of his or her medications because there are combinations of drugs that work in different ways with different blood
glucose control and side effects.
● Check viability of insulin
○ Emphasize the importance of checking expiration dates of medications, inspecting insulin for cloudiness if it is normally clear, and monitoring proper
storage and preparation because these affect insulin absorbability.
● Check injection sites periodically.
○ Insulin absorption can vary day to day in healthy sites and is less absorbable in lipohypertrophic tissues
● Administer prescribed IV fluids
○ To prevent dehydration
● Monitor antibiotic toxicity, BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels, and coagulation studies.
○ To monitor blood levels and be able to provide immediate interventions as needed.

I. MEDICAL/SURGICAL MANAGEMENT (Reg)

 MEDICAL MANAGEMENT SURGICAL MANAGEMENT

1. Empiric Antimicrobial ● Initial selection of particular
Therapy antimicrobial agents is empiric
and is based on an assessment of
the patient’s underlying host
defenses, the potential sources of
infection, and the most likely
pathogens.
● Antibiotics must be
broad-spectrum and must cover
gram-positive, gram-negative, and
anaerobic bacteria because all of
these classes of organisms
produce identical clinical pictures.
Administer antibiotics
parenterally in doses high enough
to achieve bactericidal serum
levels. Many studies have found
that clinical improvement
correlates with the achievement of
serum bactericidal levels rather
than with the number of
antibiotics administered.
1. Surgical Drainage and
Debridement
● Patients with infected foci
should be taken for definitive
surgical treatment after initial
resuscitation and
administration of antibiotics.
When an infected focus
persists, there is little to be
gained from spending hours
on attempting to stabilize the
patient.
● Infectious processes require
expeditious surgical drainage
or debridement for source
control, even if the patient
does not appear stable.
Without emergency surgical
treatment, the patient’s
condition may not improve.

2. Vasopressor Therapy ● When proper fluid resuscitation

fails to restore hemodynamic
stability and tissue perfusion,
initiate therapy with vasopressor
agents. The agents used are
norepinephrine, epinephrine,
vasopressin, dopamine, and
phenylephrine. These drugs
maintain adequate blood pressure
during life-threatening
hypotension and preserve
perfusion pressure for optimizing
flow in various organs. Maintain
the mean BP required for

2. Recombinant Human
Activated Protein C Therapy
3. Corticosteroid Therapy
adequate splanchnic and renal
perfusion (mean arterial pressure
[MAP] of 65 mm Hg) on the basis
of clinical indices for organ
perfusion.
● Activated protein C is an
endogenous protein that not only
promotes fibrinolysis and inhibits
thrombosis and inflammation but
also may modulate the
coagulation and inflammation of
severe sepsis. Sepsis reduces the
level of protein C and inhibits
conversion of protein C to
activated protein C.
Administration of recombinant
activated protein C inhibits
thrombosis and inflammation,
promotes fibrinolysis, and
modulates coagulation and
inflammation.
● Hydrocortisone can be given at
200-300 mg/day for up to 7 days
or until vasopressor support is no
longer required for patients with
refractory septic shock.
● Hydrocortisone plus
fludrocortisone for adults with
septic shock, reducing the time on
ventilator and the severity of
acute kidney injury, along with
overall lower Sequential Organ
Failure Assessment (SOFA)
scores. Thus, it is reasonable to
provide stress-dose steroid
coverage plus mineralocorticoid
supplement to septic shock
 patients, and especially those who
have the possibility of adrenal
suppression.

J. DRUG ANALYSIS
Drug Classification Examples (Generic Name) Indication Mechanism Of Action Contraindications Nursing Responsibilities

Bronchodilators ● Albuterol For patients that have Relaxes the muscles around ● Hypersensitivit 1. Assess for possible
● Salbutamol lower than optimal airflow the airways and helps clear y contraindications or cautions: any
● Salmeterol through the lungs mucus from the lungs. ● Overactive known allergies to prevent
● Formoterol thyroid gland hypersensitivity reactions; cigarette
● Vilanterol Bronchodilators target the ● Hypokalemia use which affects the metabolism
beta-2 receptor, which is a ● Lactating of the drug; peptic ulcer, gastritis,
G-protein coupled receptor, ● Pregnant renal or hepatic dysfunction, and
in the lung airways. When coronary disease
the beta-2 receptor is Rationale: These conditions can be
activated, the smooth muscle exacerbated and require caution.
of the airway relaxes.
2. Perform a physical examination to
establish baseline data
Rationale: To assess the effectiveness of the
drug and the occurrence of any adverse
effects associated with drug therapy.

3. Monitor patient response to the

drug (e.g., relief of respiratory
difficulty, improved airflow)
Rationale: To determine the effectiveness
of the drug dose and to adjust dose as
needed.

4. Monitor blood pressure, pulse,

cardiac auscultation, peripheral
perfusion, and baseline
electrocardiogram
Rationale: To provide a baseline for effects
on the cardiovascular system.
 5. Provide comfort measures
including rest periods, quiet
environment, dietary control of
caffeine, and headache therapy as
needed
Rationale: To help the patient cope with the
effects of drug therapy.

6. Encourage the patient to void

before each dose of medication
Rationale: To avoid urinary retention
related to drug effects.

7. Provide small, frequent meals and

sugarless lozenges
Rationale: To relieve dry mouth and GI
upset.

8. Review the use of inhalator with

the patient; caution the patient not
to exceed 12 inhalations in 24
hours
Rationale: To prevent serious adverse
effects.

[Drug Class 3] ● Warfarin (Coumadin) To help prevent clots from Anticoagulants achieve their ● Uncontrolled 1. Conduct thorough physical
Anticoagulants ● Apixaban (Eliquis) forming effect by suppressing the bleeding assessment before beginning drug
● Dabigatran (Pradaxa) synthesis or function of ● Open wounds therapy
● Edoxaban (Lixiana) various clotting factors that ● Active ulcer Rationale: To establish baseline status,
● Rivaroxaban (Xarelto) are normally present in the disease determine effectivity of therapy, and
blood. Such drugs are often ● Recent brain, evaluate potential adverse effects.
used to prevent the formation eye or spinal
of blood clots (thrombi) in cord injury or 2. Obtain baseline status for complete
the veins or arteries or the surgery blood count and clotting studies
enlargement of a clot that is ● Severe liver or Rationale: To determine any potential
circulating in the kidney disease adverse effects.
bloodstream. ● Uncontrolled
hypertension 3. Assess for signs signifying blood
 ● Pregnancy loss (e.g. petechiae, bruises,
dark-colored stools, etc.)
Rationale: To determine therapy
effectiveness and promote prompt
intervention for bleeding episodes.

4. Establish safety precautions (e.g.

raising side rails, ensuring adequate
room lighting, padding sides of
bed, etc.)
Rationale: To protect patient from injury.

5. Maintain antidotes on bedside (e.g.

protamine sulfate for heparin,
Vitamin K for warfarin)
Rationale: To promptly treat drug overdose

6. Monitor the following blood tests:

prothrombin time (PT) and
international normalized ratio
(INR) for warfarin; and whole
blood clotting time (WBCT) and
activated partial thromboplastin
time (APTT) for heparin.
Rationale: To evaluate effectiveness

7. Educate patient on drug therapy

including drug name, its indication,
and adverse effects to watch out
for.
Rationale: To enhance patient
understanding on drug therapy and thereby
promote adherence to drug regimen.

Antidiabetic Agents ● Biguanide To control the amount of Mechanisms of action ● Allergy to 1. Perform a complete physical
(metformin) glucose in the blood include diminution of free sulfonylureas assessment to establish baseline
● Meglitinide fatty acid accumulation, and other status before beginning therapy
(nateglinide) reduction in inflammatory antidiabetic Rationale: To evaluate effectiveness and
● thiazolidinedione cytokines, rising adiponectin agents any potential adverse effects during
 (TZD) (pioglitazone) levels, and preservation of ● Type 1 therapy.
● dipeptidyl peptidase 4 β-cell integrity and function, diabetes
(DPP-4) (linagliptin) all leading to improvement ● Pregnancy and 2. Assess orientation and reflexes;
● α-glucosidase of insulin resistance and lactation baseline pulse and blood pressure;
inhibitors (acarbose β-cell exhaustion adventitious breath sounds;
miglitol) abdominal sounds and function
● Sulfonylureas Rationale: To monitor effects of altered
(chlorpropamide) glucose levels.

3. Investigate nutritional intake,

noting any problems with intake
and adherence to prescribed diet
Rationale: To help prevent adverse
reactions to drug therapy.

4. Assess activity level, including

amount and degree of exercise
Rationale: This can alter serum glucose
levels and dosage needs for these drugs.

5. Monitor blood glucose levels as

ordered
Rationale: To evaluate effectiveness of drug
and glycemic control.

6. Monitor results of laboratory tests,

including urinalysis, for evidence
of glycosuria, and renal and liver
function tests
Rationale: To determine the need for
possible dose adjustment and evaluate for
signs of toxicity.

7. Administer the drug as prescribed

in the appropriate relationship to
meals
Rationale: To ensure therapeutic
effectiveness.

Antibiotics ● Cefotaxime (Claforan) used to treat some types of disrupt essential processes or
● Ceftriaxone (Rocephin)
● Cefuroxime (Zinacef,
Ceftin)
● Ticarcillin-clavulanate
(Timentin)
● Piperacillin-tazobactam
(Zosyn)
● Imipenem-cilastatin
(Primaxin)
● Meropenem (Merrem)
● Clindamycin (Cleocin)
● Metronidazole (Flagyl)
● Ciprofloxacin (Cipro)
bacterial infection. structures in the bacterial
cell. This either kills the
bacterium or slows down
bacterial growth.
Depending on these
effects an antibiotic is
said to be bactericidal or
bacteriostatic.
8. Monitor patients during times of
trauma, pregnancy, or severe stress,
and arrange
Rationale: To switch to insulin coverage as
needed
9. Provide patient education about
drug effects and warning signs to
report
Rationale: To enhance patient knowledge
and to promote compliance.
● hypersensitivit 1. Assess for the mentioned cautions
y and contraindications (e.g. drug
● Renal failure allergies, CNS depression, CV
● Hepatic failure disorders, etc.)
● Pregnancy and Rationale: to prevent any untoward
lactation complications.
●
2. Perform a thorough physical
assessment (other medications
taken, CNS, skin, respirations, and
laboratory tests like renal functions
tests and complete blood count or
CBC)
Rationale: to establish baseline data before
drug therapy begins, to determine
effectiveness of therapy, and to evaluate for
occurrence of any adverse effects
associated with drug therapy.
3. Perform culture and sensitivity
tests at the site of infection
Rationale: to ensure appropriate use of the
drug.

Isotonic crystalloid ● Dopamine
● Norepinephrine
(Levophed)
● Vasopressin (Pitressin)
Used to increase the Increase cardiac output
efficiency and
improve the
contraction of the
heart muscle, which
leads to improved
blood flow to all
tissues of the body.
These drugs have long
been used to treat
heart failure, a
condition in which the
heart cannot pump
enough blood to meet
the tissue needs of the
body.
4. Conduct orientation and reflex
assessment, as well as auditory
testing
Rationale: to evaluate any CNS effects of
the drug (aminoglycosides).
● Presence of 1. Assess for the mentioned
through positive digitalis contraindications to this drug (e.g.
inotropic activity (an toxicity and in renal insufficiency, acute MI,
increase in the force of patients with hypersensitivity, etc.)
the contraction). They known Rationale: to prevent potential adverse
slow the conduction hypersensitivit effects.
velocity through the y
atrioventricular (AV) ● Ventricular 2. Conduct thorough physical
node in the heart and failure assessment before beginning drug
decrease the heart rate ● Ventricular therapy
through a negative tachycardia Rationale: to establish baseline status,
chronotropic effect ● Cardiac determine effectivity of therapy and
tamponade evaluate potential adverse effects.
● Restrictive
cardiomyopath 3. Assess closely patient’s heart rate
y or AV block. and blood pressure
Rationale: to identify cardiovascular
changes that may warrant a change in
digoxin drug dose.
4. Auscultate heart sounds
Rationale: to note the presence of abnormal
sounds and possible conduction problems.
5. Obtain baseline electrocardiogram
(ECG)
Rationale: to identify heart rate and rhythm.
6. Monitor serum electrolyte and
renal function test results
Rationale: to determine whether changes in
drug dose is needed or not.
 7. Determine urinary pattern and
output
Rationale: to assess gross indication of
renal function.