ICU CASE

PRESENTATION
GROUP 1B
Labaco, Nicanor
Navarro, Erby May
Kusain, Jaya Normina
Ranes, Jayne Kathleen
Labanero, Kristine Hope
 Ongoing Diagnosis:
SEPTIC SHOCK SECONDARY
TO ASCENDING
CHOLANGITIS s/p ERCP
Endoscopic retrograde
cholangiopancreatography
Biographic
Data:
Name: ABCDEFU
Age: 58 years old
Gender: Female
Date of Birth: January 1, 1964
Address: Labangal, Gensan City
Religion: Roman Catholic
Nationality: Filipino
Informants: Patient and sister (good
reliability)
Chief Complain: Abdominal Pain
 History of Present Illness:

• Experienced epigastric pain (6/10)

after eating breakfast
• Pain was described as crushing and
MORNING PTA intermittent lasting for 30 minutes,
with radiation to the back
• No associated fever, nausea,
vomiting, and changes in bowel
movement
 History of Present Illness:

• Epigastric pain (6/10) persisted

AFTERNOON PTA • With associated chills and
undocumented fever
• Persistence of symptoms prompted
consult at TMC-ER and subsequent
admission
 Other history:
Pertinent ROS Past Medical History

• No weight gain or weight loss, easy • (+) Hypertension -20 years

fatigability • 2005 – open cholecystectomy with
• (+) generalized weakness biliary stent insertion
• No headache, seizures, blurring of • 2007 – biliary stent replacement
vision, ear problems • Allergic to erythromycin - rashes
• No dyspnea, cough, colds
• No palpitation, chest pain
• No nausea, vomiting
• No dysuria,
 Other history:
Family History Personal-Social History

• Hypertension • Annuled
• Asthma • Smoker
• Occasional alcohol beverage drinker
• Usual diet: prefers meat and fatty
food, soda
Assessment:
• CC: Abdominal pain (epigastric, RUQ areas)
• Accompanied by chills and fever
• Past medical history of cholecystectomy with biliary stent
insertion and replacement (2005 and 2007)
• Acute onset
• Hypertensive, smoker
• Overweight (BMI=29.4)
• At the ER: febrile and hypotensive
• Icteric sclerae and jaundiced
• Epigastric and RUQ tenderness
Assessment:
• CNS – Off midazolam; GCS 15
• CVS – off levophed (11/30); noted atrial fibrillation (11/30);
ECG (12/1): left atrial enlargement, leftward deviation
• Respiratory – weaning
• GI – NGT (supportan-1200kcal/day); jaundiced
• GU – Creatinine=16.83mg/dl GFR of 38.4 (CKD Stage 3)
• Hematology – anemia (Hb=9.5 “L”; Hct=28 “L”)
• Infectious – on ampicillin and ceftriaxone day 1
Septic Shock
Septic shock is a severe complication of sepsis that can include very
low blood pressure, an altered mental state, and organ dysfunction.
It has a hospital mortality rate of 30–50 percent, making it very
dangerous if not treated quickly.

Sepsis can result from a bacterial, fungal, or viral infection. These

infections may begin at home or while you’re in the hospital for
treatment of another condition.

Septic shock is what happens when sepsis itself isn’t diagnosed or

treated in time.
 Ascending Cholangitis
Ascending cholangitis is the historical term for the condition currently
referred to as acute cholangitis or simply as cholangitis.

Acute cholangitis is an infection of the biliary tree, most commonly

caused by obstruction. In its less severe form, there is biliary obstruction
with inflammation and bacterial seeding and growth in the biliary tree. It is
estimated that 50% to 70% of these patients present with right upper
quadrant pain, fever, and jaundice. In the more severe, life-threatening
form, known as toxic cholangitis or cholangitis with sepsis, patients have
purulent biliary tree contents, as well as evidence of sepsis, hypotension,
multiorgan failure, and mental status changes.
Ascending Cholangitis
Ascending cholangitis is also a potential complication of
endoscopic retrograde cholangiopancreatography (ERCP).
Reported mortality rates in different series for post-ERCP
cholangitis range between 10 and 16%. Ascending cholangitis
results from bacterial infection of an obstructed biliary system,
usually from enteric Gram-negative rods, resulting in bacteremia.
Incomplete drainage of the biliary system after ERCP occurs in up
to 10% of patients who require stenting. It has been suggested that
appropriate early antibiotic therapy in this group of patients would
probably reduce the frequency of cholangitis post-ERCP by 80%.
EPIDEMIOLOGY AND RISK
FACTORS
The most frequent causes of biliary obstruction in patients with acute cholangitis without
bile duct stents are biliary calculi (28 to 70 percent), benign biliary stricture (5 to 28 percent),
and malignancy (10 to 57 percent). Malignant obstruction may be due to the presence of tumor
in the gallbladder, bile duct, ampulla, duodenum, or pancreas.

Acute cholangitis can also occur following endoscopic retrograde

cholangiopancreatography (0.5 to 1.7 percent), particularly therapeutic endoscopic retrograde
cholangiopancreatography following stent placement, or postoperatively due to bile duct injury,
or a strictured biliary-enteric anastomosis (pancreaticoduodenectomy, liver transplantation, liver
resection, and Roux-en-Y hepaticojejunostomy). Rarely, the distal common bile duct may be
obstructed by food, stones, or debris in patients with a biliary-enteric anastomosis (Sump
syndrome)
Laboratory Test
• Complete blood count (CBC). A CBC blood test is used to measure
your white blood cell count. If you have an infection, your white blood cell
count will likely be elevated.
• Liver function tests. Liver function tests can help determine whether
your liver is functioning properly and if your liver enzymes are within a
normal range.
• Anti-mitochondrial antibody test. The presence of anti-mitochondrial
antibodies (AMAs), along with the results from other blood work, may be
an indication of cholangitis.
• Cholesterol test. A cholesterol test can be helpful in determining your
risk factor for gallstones, which can lead to cholangitis.
• Blood culture. A blood culture test can tell your doctor if you have a
blood infection.
Diagnostic Procedure
• Ultrasound. An ultrasound uses high-frequency sound waves to capture
live images from the inside of your body. It allows your doctor to see any
potential issues with your organs and blood vessels without needing to
make an incision. For diagnosing cholangitis, an ultrasound will focus on
your liver, gallbladder, and bile ducts.
• CT scan. A CT scan is a form of X-ray that creates detailed images of
your internal organs and body structures. For diagnosing cholangitis, a
dye may be injected intravenously, which helps to show if there is a
blockage in the bile ducts.
• Magnetic resonance cholangiopancreatography (MRCP). This is a
special type of magnetic resonance imaging (MRI) exam that produces
detailed pictures of your liver, gallbladder, and bile ducts. It can also
show if there are gallstones in your bile duct or any type of blockage.
Diagnostic Procedure
• Endoscopic retrograde cholangiopancreatography (ERCP). This
procedure combines an X-ray and the use of a long, flexible tube with a
light and camera on the end, called an endoscope. Your doctor will guide
the scope down your throat into your stomach and then into the first part
of your intestine. This will allow them to view your organs for any
problems. They will then inject a dye into your bile ducts and take an X-
ray to see if there is a blockage.
• Percutaneous transhepatic cholangiography (PTC). With this
procedure, a contrasting agent (dye) is injected through your skin into
your liver or bile duct. Then, you’ll get an X-ray of the ducts to determine
if there’s an obstruction. Because of the invasive nature of this
procedure, it’s used a lot less frequently than the procedures listed
above.
 Focus Physical Exam
GENERAL APPEARANCE: The patient is conscious, alert and
coherent, with coordinated movement, no body/minor body odor; no breath
odor. She is overweight with a BMI of 29.4; baseline vital signs of BP =
83/55 mmhg (hypotensive), T= 39.5oC (febrile), RR = 21 (non-labored),
HR = 88 (normal rate and rhythm). Guarding behavior is observed in the
right upper quadrant of the abdomen. Jaundice in the extremities and body
malaise are observed. She is cooperative; the mood is appropriate to
situation; quality of speech is understandable.
 Body Parts & Inspection Palpation Percussion Auscultation Interpretation
History
Skin Skin color: jaundice Skin     Hepatitis produces jaundice, which is a
  in the extremities  temperature: yellowing of the skin, nail beds, and
- Patient is allergic   warm to touch whites of the eyes, as well as light
to erythromycin feces and black urine. . The
accumulation of a greenish–yellow
(rashes). T- 39.5C material (known as bilirubin) in the
    blood and tissues of the body causes
- Patient is anemic this (Dr. Mandal, 2019).
(Hb=9.5; Hct=28)
The fevers that trigger febrile seizures
are usually caused by infection ( Dillon
Health Assessment, 2006).
 
Nails Nail beds are       Hepatitis produces jaundice, which is a
  yellowish yellowing of the skin, nail beds, and
- Patient has   whites of the eyes, as well as light
history of feces and black urine. . The
cholecystectomy. accumulation of a greenish–yellow
material (known as bilirubin) in the
blood and tissues of the body causes
this (Dr. Mandal, 2019).
 

Hair Evenness of growth Thickness or Not Applicable Not Applicable Normal Findings
No history of any over the scalp: Evenly thinness of  
hair disease distributed hair: Thick ( Dillon Health Assessment, 2006).
  hair
   
Texture & oiliness:
Silky and resilient hair
 
Presence of infections
or infestations: No
infection or infestation
 
 Body Parts & Inspection Palpation Percussion Auscultation Interpretation
History
Head Size, shape and symmetry: Rounded, Not Applicable Not Applicable Not Applicable Normal Findings (Dillon, 2006).
smooth skull contour .
   
Absence of nodules and masses
 
Facial features: Symmetric/ slightly
asymmetric
 
 
Symmetry of facial movements:
Symmetric facial moveents

Ears Auricles (color, symmetry, and position): Not Applicable Not Applicable Not Applicable Impaired excretion of urinary
Grayish-bronze color (sallow); pigments (urochromes) as well as the
symmetrical; aligned with outer canthus presence of anemia due to lack of
of eye erythropoetin being produced
  (Pietrangelo, 2019)..
Client’s response to normal voice tones:  
normal voice tone audible  
 
Eyes Sclera: Icteric       Icteric sclera refers to the yellowing
  Palpebral conjunctiva: Pink of the white area of your eye, which
- Patient has history of   is a sign of jaundice. Jaundice can be
cholecystectomy. caused by a number of illnesses,
  including disorders with the liver,
- Patient is anemic pancreas, or gallbladder (Griff, 2020).
(Hb=9.5; Hct=28)  
 Body Parts & Inspection Palpation Percussion Auscultation Interpretation
History
Mouth and Throat Outer and inner lips for Not Applicable Not Applicable Not Applicable Due to excessive
symmetry of contour, dryness, decrease
color and texture: hydration and impaired
Pallor, fissures and circulation(Dillon, 2006).
dryness  
   
Condition of teeth: Teeth
is smooth, yellowish in
color
 
Position of tongue,
presence of lesion:
Central position; no
lesion
 
Neck No lesion, lumps noted Neck muscles for Not Applicable Not Applicable Normal Findings
abnormal swelling or (Dillon, 2006).
masses: Muscle equal  
in size; head centered
 
Enlargement of lymph
nodes: Lymph node
not palpable
 
Breasts Breasts are No lump and masses Not Applicable Not Applicable Normally, Breasts are
asymmetrical. noted asymmetrical, and non-
No lesions noted tender.
(Dillon, 2006)
 
 Body Parts & History Inspection Palpation Percussio Auscultatio Interpretation
n n
Thorax and Back (cardio-pulmo) Chest     Clear breath Atrial fibrillation (AFib) is the
  expansion are sounds. most common problem with
- Patient has history of asthma and smoking. symmetrical. your heartbeat's rate or rhythm.
  Weaning noted The basic cause of AFib is
-noted atrial fibrillation (11/30); ECG (12/1): during disorganized signals that make
left atrial enlargement, leftward deviation expiration. your heart's two upper chambers
  (the atria) squeeze very fast and
- Hematology – anemia (Hb=9.5; Hct=28) out of sync (Dillon, 2006).
 
• Respiratory – weaning
Abdomen Protuberant No masses Tympanitic Bowel Protuberant abdomen is a
  palpated. sound sounds: 5 condition in which the
abdomen becomes unusually
- Patient has epigastric pain with a rate of Tenderness clicks per convex due to inadequate
6/10, and right upper quadrant tenderness. upon minute muscular tone or extra
  palpation (normoactiv subcutaneous fat. In the case of
- Patient is an occasional alcohol beverage e). the patient, his diet consists
drinker. primarily of meat, fatty meals,
and soda, all of which are high
  in fats and contribute to his
- Patient’s usual diet: prefers meat, fatty obesity (Driscoll, 2020).
foods, and soda.  
 
 Body Parts & Inspection Palpation Percussion Auscultation Interpretation
History
 Genito-Urinary Urine color light Yellow Not able to assess Not Not Applicable It contains RBCs, WBCs and
– Transparency is turbid Applicable pus which indicates
Creatinine=16.83m  
g/dl  GFR of 38.4 malfunction of the kidneys to
(CKD Stage 3)
reabsorb and filters
(Bruners and Suddart, 2018).
 
Musculoskeletal/ Jaundiced in the Full and equal pulses.     Hepatitis produces jaundice,
Extremities extremities. Good skin which is a yellowing of the
  turgor. skin, nail beds, and whites of
Height: 152 cm   the eyes, as well as light feces
and black urine. . The
Weight: 68 kg   accumulation of a greenish–
    yellow material (known as
BMI: 29.4 bilirubin) in the blood and
(overweight) tissues of the body causes
this (Dr. Mandal, 2019).
 

• Vitals Sign T: 39.5oC (at ER), 36.4oC (ICU),

RR: 21cpm
BP: 83/55 (at the ER), 125/65 (ICU)
HR: 88 bpm
 Laboratory Tests Rationale
CBC with differential count Baseline values; determine the presence of
infection, anemia, etc.
Electrolyte panel with renal function Assess metabolic state and kidney function
Liver function test Determine possible liver pathology (e.g.) hepatitis
Prothrombin time/activated partial Coagulopathies (e.g., DIC. Cirrhosis)
thromboplastin time
Lipase Usually elevated in pancreatitis
Urinalysis Baseline values; determine the presence of
infection, glucose, protein, etc.
Culture and sensitivity for blood, blood Determine foci of infection and resistance profiles
and stent
Chest x-ray Baseline data
Ultrasound Visualization of the biliary tree
 Complete Blood Count
Diagnostic/Laboratory Normal Values Result Analysis and Interpretation

HEMATOLOGY:

Leukocytes 5.0-10.0 / mm3 21.70 “H” Result was above normal. This
shows that there is presence of
infection.

Erythrocytes 4.2-5.4 / mm3 3.24 “L” Result was below normal. This
indicates alteration in
erythropoietin production
secondary to renal malfunction.

Hemoglobin 11.0-15.0 / mm3 9.5 “L” Result was below normal. This
shows the decrease in the
oxygen carrying capacity of the
blood secondary low
hematocrit..

Hematocrit 37.0-47.0 / mm3 28 “L” Result was below normal, thus

showing anemia related to
insufficient RBC production.
Thrombocytes 150-450 / mm3 442 Normal.

Neutrophils 50-70 / mm3 89.200 “H” Result shows increased in

normal level, indicating
bacterial infection.

Lymphocytes 20.0-40.0 / mm3 55.00 “H” Result is above the

normal range, indicating
bacterial infection.

Monocytes 0.0-7.0 / mm3 3.800 Normal.

Eosinophils 0.00-5.00 / mm3 1.200 Normal.

Basophils 0.000-1.000 / mm3 0.300 Normal.

Chemistry
CHEMISTRY: Normal value Result Analysis

7-20 111 mg/dl “H” Result was above the

Blood Urea Nitrogen normal range
indicating renal
malfunction.

0.52-1.25 16.83mg/dl “H” Result was above

Creatinine normal thus showing
inability of the kidney
to excrete
nitrogenous waste.

137-145 150 mmol/l “H” Result shows an

Sodium increased in normal
level of sodium, thus
suggesting renal
dysfunction.
 Normal value Result Analysis
3.5-5.1 6.2 mmol/l ”H” Result shows an
Potassium increased in normal
level of potassium,
thus suggesting
renal dysfunction.

2.5-4.5 12.9mg/dl ”H” Result shows an

Phosphorus increased in normal
level of phosphorus,
thus suggesting
renal dysfunction.

Calcium 1.12-1.32 1.08mmol/l ”H” Result shows an

increased in normal
level of calcium,
thus indicating renal
dysfunction.
 Urinalysis
Result Analysis
Presence of blood in the
Physical Color Bright Red urine.

Reaction 8.5 ph Substance in the body that

contribute to the acidity level
of the blood remains, and this
inability to concentrate urine
may be a cause of renal

dysfunction.
Transparency Turbid It contains RBCs, WBCs
and pus which indicates

malfunction of the kidneys

to
reabsorb and
filters.
Specific Gravity 1.010 Normal
 Result Analysis

Albumin +++ Increased albumin excretion is

an indicative of increased
permeability of the filters of
kidney (glumerolus), and may
be caused by disease (diabetes,
hypertension, lupus, infections,
nephritis).
Sugar Trace High level of glucose and other
sugar in the urine can be caused
by advanced kidney disease,
impaired tubular reabsorption.  
Pus cells There is presence of bacterial
4-6/hpf infection as evidenced by
presence of bacteria, pus cells and
RBCs.

RBC 0-2/hpf

Epithelial cells Many

Bacteria Few
Ultrasound
Result
Findings:

Ultrasound show biliary dilatation with calculi, with pus,

which appears as debris material within the common bile
duct.

Analysis:
Intrahepatic and/or extrahepatic duct dilatation (indicating
obstruction/stasis). Bile duct wall thickening or focal
outpouchings
Chest X-Ray
Result
Findings:

Chest AP view shows congestive changes in both lungs.

Heart is magnified.
 
Analysis:
Congestion is due to pulmonary edema. Retention of
Na and H2O.
Medical Management
Septic Shock
• Close monitoring (vital
signs, I/O)
• Hemodynamic support with
IV fluids and vasopressors
• Identify underlying cause for
sepsis
Ascending Cholangitis
• ABC assessment IV Fluid
resuscitation with
crystalloids (e.g. plain NSS)
• Parenteral antibiotics Biliary
decompression (severe
cases)
• Extracorporeal shockwave
lithotripsy (ESWL) for
choleliths
Medical Management:
1. Intravenous antibiotics to fight infection
2. Vasopressor medications, which are drugs that constrict blood vessels and help increase
blood pressure
3. Insulin for blood sugar stability corticosteroids
4. Large amounts of intravenous (IV) fluids will likely be administered to treat dehydration
and help increase blood pressure and blood flow to the organs. A respirator for breathing
may also be necessary.
Nursing Management
 Monitor vital signs
 Assess neurovitals
 Obtain cultures (blood, urine, sputum)
 Administer antibiotics
 Check labs for electrolytes, renal and liver function
 Ensure patient has DVT and pressure sore prophylaxis
 Consult with dietitian regarding feeding
 Assess oxygenation and ventilation
 Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
 Obtain a baseline measurement.
 Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45
degrees for one minute.
 Obtain subsequent measurement.
 Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and
oxygen saturation.
3 NURSING CARE PLAN
1. Decreased Cardiac Output rt Alteration in heart rate, rhythm, and
conduction secondary to septick shock
2. Acute abdominal pain r/t obstruction/ductal spasm
3. Altered Renal Perfusion RT Glomerular Malfunction
 NCP #3
Altered Renal Perfusion RT Glomerular Malfunction
 Assessment Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation
and Intervention
Subjective Nursing Goal: Facilitate the Independent: After 8 hours of
Cues: Diagnosis: maintenance of   nursing intervention,
“Napapansin ko Altered Renal electrolyte balance. 1. Establish rapport 1. To get the Goal met the patient
po maam habang Perfusion RT     cooperation of the was able to:
  patient and SO.
umiihi po ako na Glomerular Objectives:
2. Monitor and record   • Demonstrate
yung ihi ko po ay Malfunction After 8hours of nursing
vital signs and assess 2. To obtain baseline participation in
kulay pula”   intervention the patient data.
patient’s general his/her
  will be able to.  
condition. recommended
Objective Cues: Inference:    
  treatment program.
 Creatinine -    Patient will  
3. Determine factors
16.83mg/dl loss of kidney demonstrate related to individual 3. To assess causative • Demonstrate
“H”) excretory participation in situation and note and contributing behaviour/lifestyle
 Haematuria functions  his/her situation that can factors changes to prevent
 BUN -111 recommended affect all body system.   complications
mg/dl “H” Impaired excretion treatment    
  of nitrogenous program. 4. Check lab results
  waste product  Patient will and note 4. To assess for
T   demonstrate characteristics of hematuria
Vital signs: Increase in urine and specific and protenuria.
behaviour/lifestyle
BP: 83/55 mmhg Laboratory result gravity.  
changes to
Temp:36.4 C of BUN,   5. To compare with
prevent current situation and
RR: 21 cpm Creatinine. complications
5. Ascertain usual may indicate pain on
PR: 88bpm     voiding pattern and affected organ.
Altered Renal
Note presence,
Perfusion location intensity
duration of pain.
Assessment Nursing Diagnosis Goals and Intervention
and Intervention Objectives
6. Monitor for dependent
generalized edema.
7. Measure urine output on a
regular schedule and weigh
daily.
8. Identify necessary changes
in lifestyle and assist client to
incorporate disease
management to ADLs.
Dependent
1.Administer medication as
ordered.
 
2. Refer to physician about
the prescribe diet that is
appropriate to the client
Collaborative:
1.Coordinate with the
nutritionist about the
prescribed diet for the patient.
2. Collaborate to the medical
tecnologist and gather
sample for labs and follow up
results
Rationale Evaluation
 6.
To note the degree of
impairment of renal function.
7. To assess renal perfusion and
function.
 
8. To promote wellness and
prevent further progression of
complications.
 
 
1. For faster recovery. It is
used to treat the client’s
disease condition.
2. Diet is one of the factors that
can help in patients’ recovery
and avoid any complications
 
1. Good nutrition can aid in
patients’ recovery.
2. To monitor any unusual
abnormalities in patient
condition.
NCP #2
Acute abdominal pain r/t obstruction/ductal spasm
 Assessment Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation
and Intervention
Subjective: Acute abdominal Goals: To facilitate Independent: After 4 hours of
patient describe pain r/t optimal activity: 1.Observe and 1.Assists in nursing intervention,
pain as crushing obstruction/ducta document location, differentiating cause of goal met; the patient
exercise, rest and
and intermittent l spasm severity (0–10 scale), pain, and provides was able to.
lasting for 30   sleep. and character of pain information about
minutes, with Inference: Objectives: After 4 (steady, intermittent, disease progression • Report pain is
radiation to the Cholangitisis the hours of nursing colicky). and resolution, relieved/controlled.
back. most serious intervention the   development of
  complication of   complications, and • Pain is reduce from
patient will be able to. 6/10 to 2/10.
Objectives: gallstones and   effectiveness of
Guarding more difficult to
-Report pain is interventions.
relieved/controlled. • Demonstrate use of
Behaviour diagnose. Itis  
-Pain is reduce from relaxation skills and
Facial mask of caused by 2.Note response to 2.Severe pain not
diversional activities
pain impacted stone in 6/10 to 2/10. medication, and relieved by routine
as indicated for
Pain scale was the common bowel -Demonstrate use of report to physician if measures may
individual situation
6/10 duct, resulting in relaxation skills and pain is not being indicate developing
(+) Generalize bile stasis, relieved. complications or need
weakness bacteremia and diversional activities   for further intervention.
  septicemia if left as indicated for 3.Bedrest in low-
Vital signs: untreated. It is individual situation. 3.Promote bedrest, Fowler’s position
BP:83/55 mmhg more likely to   allowing patient to reduces intra-
Temp:36.4 C occur when an assume position of abdominal pressure.
RR: 21 cpm already infected comfort.  
PR: 88bpm 4.Promotes rest,
4.Encourage use of redirects attention,
relaxation techniques. may enhance coping
Provide diversional
activities.
Assessment Nursing Diagnosis Goals and Intervention Rationale Evaluation
and Intervention Objectives
5.Control 5.Cool surroundings
environmental aid in minimizing
temperature. dermal discomfort.
   
6.Make time to listen 6.Helpful in alleviating 
to and maintain anxiety and refocusing
frequent contact with attention, which can
patient. relieve pain.
   
Dependent:  

1.Maintain NPO 1.. Removes gastric

status, insert and/or secretions that
maintain NG suction stimulate release of
as indicated. cholecystokinin and
gallbladder
contractions.
2. Administer 2. For faster recovery.
medication as It is used to treat the
ordered. client’s disease
condition.
 NCP #1
Decreased Cardiac Output rt Alteration in heart rate, rhythm,
and conduction secondary to septick shock
 Assessment Nursing Goals and Objectives Intervention Rationale Evaluation
Diagnosis and
Intervention
Subjective Decreased Goals: To facilitate the Independent:   After 4 hours of nursing
Cues: Cardiac maintenance of intervention, Goal
1.For patients with 1.Fluid restriction decreases
Output rt regulatory mechanism met;the patient was be
 Patient Alteration in and functions. increased preload, the extracellular fluid volume
and reduces demands on able to;
verbalized “ heart rate, Objectives: limit fluids and
nahihirapan po rhythm, and After 4 hours of sodium as ordered. the heart.
akong huminga” conduction nuraing intervention 2. In patients with decreased
secondary to the patient will be able 2.  Closely monitor 1.Patient demonstrates
Objective Cues: fluid intake, including cardiac output, poorly adequate cardiac
septick to;
shock IV lines. Maintain functioning ventricles may output as evidenced by
 Noted atrial not tolerate increased fluid blood pressure and
  1.Patient demonstrates fluid restriction if
fibrillation Inference: adequate cardiac ordered. volumes. pulse rate and rhythm
(11/30); Decrease output as evidenced by within normal
ECG (12/1): 3. If chest pain is 3. These actions can
Contractability blood pressure and parameters.
 left atrial present, have the increase oxygen delivery to
  pulse rate and rhythm
enlargement Ventricle within normal patient lie down, the coronary arteries and 2.Patient exhibits
 leftward dilates to parameters. monitor cardiac improve patient prognosis. warm, dry skin, eupnea
deviation increase 2.Patient exhibits rhythm, give oxygen, Symptoms can also be with absence of
contractability warm, dry skin, run a strip, medicate manifestations of myocardial pulmonary crackles.
from stretched eupnea with absence for pain, and notify ischemia and should be
muscle fibers of pulmonary crackles. the physician. reported immediately. 3.Patient remains free
Vital signs: of side effects from the
  3.Patient remains free
BP: 83/55 mmhg Increase of side effects from the 4.  Place on a cardiac 4. Atrial fibrillation is medications used to
ventricular medications used to monitor; monitor for common in heart failure and achieve adequate
Temp:36.4 C radius results achieve adequate dysrhythmias, can cause a thromboembolic cardiac output.
in increase cardiac output. especially atrial event.
RR: 21 cpm
wall tension fibrillation
PR: 88bpm
Assessment Nursing Goals and Intervention Rationale Evaluation
Diagnosis and Objectives
Intervention
Increase oxygen 4.Patient explains 5. Observe patient for 5. This promotes the 4.Patient explains
consumption actions and understanding and cooperation of the patient in actions and
and increase compliance with medical their own medical situation.
precautions to take regimen, including
precautions to
cardiac for cardiac disease take for cardiac
medications, activity level,
workload disease
and diet.
 
Cardiac output .
falls
  Dependent: 1. The failing heart may not be
Increase 1.Administer oxygen therapy able to respond to increased
sympathetic as prescribed. oxygen demands. Oxygen
outflow to saturation needs to be
increase heart greater than 90%.
rate and
systemic 2. Depending on etiological
2. Administer medications as factors, common medications
vascular prescribed, noting side effects include digitalis therapy,
resistance and toxicity. diuretics, vasodilator therapy,
 
antidysrhythmics, angiotensin-
Stroke volume
converting enzyme inhibitors,
falls
and inotropic agents.
 

Decrease
cardiac output
Drug
Study
DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICA INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) TION and Actual)
Brand Pharmaco
name: logical:
Versed   The actions of  Anterograde
  Benzodiaz benzodiazepines amnesia
epines such as midazolam Recommended  Euphoria  Monitor and record
  :
  are mediated through  Ataxia patient response to
Generic   the inhibitory  Falls and medication and
Intubated
name:   neurotransmitter Confusion in the level of sedation.  
Patients, 0.05–
    gamma-aminobutyric 0.2 mg/kg/h by elderly  Continuous
Midazolam Intravenous
Therapeu acid (GABA), which is continuous   cardiorespiratory
  tic: one of the major Indicated for promoting infusion  Thrombophlebitis, monitoring.
  inhibitory preoperative sedation, thrombosis, and  Inspect insertion
Antianxiet neurotransmitters in anxiolysis, anesthesia IV Induction pain on injection site for redness,
y agents, induction, or amnesia. for General pain, swelling, and
the central nervous  
Anesthesia other signs of
Anxiolytics system.    Hypotension and extravasation during
, Benzodiazepines Adult: tachycardia can IV infusion.
Anticonvul increase the activity   IV occur with rapid
sants of GABA, thereby Premedicated, intravenous  Monitor for
producing a sedating 0.15–0.25 administration. A hypotension,
mg/kg over especially if the
effect, relaxing higher dose can
20–30 s, allow patient is
skeletal muscles, and result in premedicated with a
2 min for effect
inducing sleep, midazolam narcotic agonist
IV
anesthesia, and infusion syndrome analgesic.
amnesia. and respiratory
Benzodiazepines depression.

#1
 DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICA INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) TION and Actual)
 
 Monitor vital signs
for entire recovery
period. In obese
• Residual hangover patient, half-life is
bind to the effect can happen prolonged during IV
benzodiazepine site CONTRAINDICATION: with nighttime infusion; therefore,
on GABA-A   administration of duration of effects is
receptors, which Caution is necessary midazolam, which prolonged (i.e.,
for pregnant individuals, can impair the
potentiates the effects amnesia,
children, and individuals cognitive and
of GABA by with comorbid postoperative
increasing the psychomotor recovery). 
psychiatric conditions.
frequency of chloride abilities, which can
Administration in elderly Actual:
channel opening. individuals and acutely result in falls in  Observe for
These receptors have ill patients requires continuous elderly and impaired overdose symptoms
been identified in caution to prevent the infusion of coordination during include
different body tissues accumulation of active 0.1mg/kg/h driving. somnolence,
including the heart metabolites. Extra confusion, sedation,
precautions should be SIDE EFFECTS: diminished reflexes,
and skeletal muscle,
taken in critically ill coma, and
although mainly  Nausea
individuals as dose untoward effects on
appear to be present accumulation can occur.  Vomiting
in the central nervous vital signs.
 Dizziness
system.  Coughing Patient Education
 Drowsiness
Do not drive or engage in
potentially hazardous
activities.
 DRUG (Brand   DOSAGE
MECHANISM OF
name and Generic CLASSIFICATI INDICATION (Recommended and ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
name) ON Actual)
Brand name: Pharmacol
  ogical:
 Monitor constantly
Levophed  
 Arrhythmias while patient is
  Catechola  Convulsions receiving
  mine  Chest pain
Indicated to restore BP in norepinephrine.
    Norepinephrine
certain acute hypotensive  Photophobia Take baseline BP
    functions as a
states such as shock. Also Recommende  Blurred vision and pulse before
Generic   peripheral
as adjunct in treatment of d:  Restlessness start of therapy,
name:   vasoconstrictor
cardiac arrest.  Anxiety then q2min from
  Therapeuti by acting on
Adult:  Tremors initiation of drug
alpha-
Norepinephri c: CONTRAINDICATION: IV Start with 8–  Pallor until stabilization
adrenergic 12 mcg/min,
ne  Plasma volume occurs at desired
receptors. It is Use as sole therapy in titrate to
Alpha and depletion level, then every 5
also an hypovolemic states, maintenance
Beta  Edema min during drug
Adrenergic
inotropic except as temporary dose of 2–4  Hemorrhage administration.
stimulator of the mcg/min
Agonist emergency measure;  Vomiting
heart and dilator  
(Sympatho mesenteric or peripheral      Observe carefully
of coronary vascular thrombosis;   and record mental
mimetic) arteries as a profound hypoxia or Actual: SIDE EFFECTS: status (index of
result of it's hypercarbia; use during 4 mcg/min IV cerebral circulation),
activity at the infusion  Headache
cyclopropane or halothane skin temperature of
beta-adrenergic anesthesia; pregnancy  Vomiting extremities, and
receptors. (category D), lactation.  Dizziness
color (especially of
 Palpitation
earlobes, lips, nail
beds) in addition to

#2 vital signs.
DRUG (Brand   DOSAGE
MECHANISM OF ADVERSE
name and CLASSIFICA INDICATION (Recommended NURSING RESPONSIBILITIES
ACTION REACTION
Generic name) TION and Actual)

 Monitor I&O. Urinary retention

and kidney shutdown are
possibilities, especially in
hypovolemic patients. Urinary
output is a sensitive indicator
of the degree of renal
perfusion. Report decrease in
urinary output or change in
I&O ratio.

 Be alert to patient's
complaints of headache,
vomiting, palpitation,
arrhythmias, chest pain,
photophobia, and blurred
vision as possible symptoms
of overdosage. Reflex
bradycardia may occur as a
result of rise in BP.

 Continue to monitor vital

signs and observe patient
closely after cessation of
therapy for clinical sign of
circulatory inadequacy
DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICA INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) TION and Actual)
Brand Pharmac Indicated for the Recommen Body as a
name: ological: treatment of mild to ded: Whole: Similar to
    moderate infections those for penicillin G.  Instruct or educate
Unasyn Aminope due to E. coli, P. Systemic Hypersensitivity the patient to take
  nicillin mirabilis, enterococci, Infections (pruritus, urticaria, ampicillin with a full
    Shigella, S. typhosa   eosinophilia, glass of water on an
    and other Salmonella, Adult: hemolytic anemia, empty stomach (at
Generic   Ampicillin is
bactericidal; it nonpenicillinase- PO 250– interstitial least 1 h before or 2
name: Therapeu h after meals) for
adheres to bacterial producing N. 500 mg q6h nephritis, anaphylact
  tic: maximum
penicillin-binding gononhoeae, H. IV/IM 250 oid reaction);
Ampicillin absorption. Food
proteins, thus influenzae, mg–2 g q6h superinfections. 
Broad hampers rate and
inhibiting bacterial cell staphylococci and  
Spectrum CNS: Convulsive extent of oral
wall synthesis. streptococci.  
Anti- absorption.
Sulbactam inhibits   Actual: seizures with high
infective  
beta-lactamase, an CONTRAINDICATION   2 g IV doses. 
 Determine previous
enzyme produced by
: hypersensitivity
ampicillin-resistant Skin: Rash.
  reactions to
bacteria that
degrades ampicillin. Hypersensitivity to SIDE EFFECTS: penicillins,
penicillin derivatives;  Diarrhea cephalosporins, and
infectious  Nausea other allergens prior
mononucleosis. to therapy.
 Vomiting
   

#3
 DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICA INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) TION and Actual)
 
 Lab tests: Baseline
C&S tests prior to
initiation of therapy.
Baseline and
periodic
assessments of
renal, hepatic, and
hematologic
functions,
particularly during
prolonged or high-
dose therapy.

 Inspect skin daily

and instruct patient
to do the same. The
appearance of a
rash should be
carefully evaluated
to differentiate a
nonallergenic
ampicillin rash from
a hypersensitivity
reaction. Report
rash promptly to
physician.
DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICATI INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) ON and Actual)
Brand Pharmacol Indicated treatment to Recommen Body as a  Determine history of
name: ogical: bacteremia, and ded: Whole: Pruritus, fever, hypersensitivity
    septicemia.  chills, pain, induration reactions to
Rocephin Third- Moderate to at IM injection site; cephalosporins and
  generation Ceftriaxone is Severe phlebitis (IV site).  penicillins and
  Cephalosp primarily Infections history of other
  orin bactericidal; it also GI: Diarrhea, abdomin allergies,
    may be Adult:  al particularly to drugs,
Generic   bacteriostatic. IV/IM 1–2 g cramps, pseudomembr before therapy is
name:   Activity depends q12–24h anous colitis, biliary initiated.
  Therapeuti on organism, (max: 4 g/d) sludge. 
 Lab tests: Check
Ceftriaxone c: tissue penetration,  
Urogenital: Genital culture and
  and dosage, and  
pruritus; moniliasis. sensitivity tests
Broad- rate of organism Actual:
before initiation of
spectrum multiplication. It  1 g IV q12- SIDE EFFECTS: therapy and
Antibiotic acts by adhering 24hr for 5-7  rash periodically during
to bacterial days therapy.
 nausea
penicillin-binding
proteins, thereby  vomiting  Inspect injection
inhibiting cell wall sites for induration
synthesis.  upset stomach and inflammation.
Rotate sites. Note
 dizziness
IV injection sites for
 headache signs of phlebitis
(redness, swelling,

#3   pain).
 DRUG (Brand   DOSAGE
MECHANISM OF
name and CLASSIFICA INDICATION (Recommended ADVERSE REACTION NURSING RESPONSIBILITIES
ACTION
Generic name) TION and Actual)
 

 Monitor for
manifestations of
hypersensitivity.
Report their
appearance
promptly and
discontinue drug.

 Watch for and

CONTRAINDICATION: report signs:
  petechiae,
Hypersensitivity to ecchymotic areas,
cephalosporins and epistaxis, or any
related antibiotics; unexplained
pregnancy (category B). bleeding.
Ceftriaxone appears
to alter vitamin K–
producing gut
bacteria; therefore,
hypoprothrombinem
ic bleeding may
occur

 
 DRUG (Brand   DOSAGE
MECHANISM OF ADVERSE
name and CLASSIFICA INDICATION (Recommended NURSING RESPONSIBILITIES
ACTION REACTION
Generic name) TION and Actual)
 
 Check for fever if diarrhea
occurs: Report both promptly.
The incidence of antibiotic-
produced pseudomembranous
colitis is higher than with most
cephalosporins. Most
vulnerable patients: chronically
ill or debilitated older adult
patients undergoing abdominal
surgery.

Reference :
 
https://go.drugbank.com/drugs/DB00683
https://www.ncbi.nlm.nih.gov/books/NBK537321/
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/M067.html
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/N042.html
https://go.drugbank.com/drugs/DB00415
https://go.drugbank.com/drugs/DB01212
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/C050.html
https://www.rxlist.com/ceftriaxone-side-effects-drug-center.htm
THANK
YOU!