General Santos Doctors’ Medical School

Foundation Inc.
Bulaong Subdivision, Barangay Dadiangas West, General Santos City

SEPTIC SHOCK SECONDARY TO ASCENDING CHOLANGITIS s/p ERCP

In Partial Fulfillment of
NCM 122 RLE

Submitted by:

Labaco, Nicanor

Navarro, Erby May

Kusain, Jaya Normina

Ranes, Jayne Kathleen

Labanero, Kristine Hope

Submitted to:

Ms. Maydilyn Gultiano, RN MAN

 January 26 ,2022

Biographic Data:

Name: ABCDEFU

Age: 58 years old

Date of Birth: January 1, 1964

Address: Labangal, Gensan City

Religion: Roman Catholic

Nationality: Filipino

Informants: Patient and sister (good reliability)

Chief Complain: RUQ Abdominal Pain

History of Present Illness:

MORNING PTA

• Experienced epigastric pain (6/10) after eating breakfast

• Pain was described as crushing and intermittent lasting for 30 minutes, with
radiation to the back

• No associated fever, nausea, vomiting, and changes in bowel movement.

AFTERNOON PTA

• Epigastric pain (6/10) persisted

• With associated chills and undocumented fever

• Persistence of symptoms prompted consult at TMC-ER and subsequent
admission.

Other history:

Pertinent ROS

• No weight gain or weight loss, easy fatigability

• (+) generalized weakness

• No headache, seizures, blurring of vision, ear problems

• No dyspnea, cough, colds

• No palpitation, chest pain

• No nausea, vomiting

• No dysuria,

Past Medical History

• (+) Hypertension -20 years

• 2005 – open cholecystectomy with biliary stent insertion

• 2007 – biliary stent replacement

• Allergic to erythromycin - rashes

Family History

• Hypertension

• Asthma
Personal-Social History

• Divorced

• 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

• 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 percentTrusted Source, 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.

Pathogenesis and Clinical Findings

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 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).

Pathogenesis and Clinical Findings

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.

 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.

Salient Features of the Patient

• 58 year old, female

• 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

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.
 GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION INC.
NCM:122n RLE EXPOSURE

Group members: Kusain, Jaya Normina; Labaco, Nicanor III; Labanero, Kristine Hope; Navarro, Erby May; Ranes, Jayne Kathleen
Year and Section: BSN 4
Group: 1B

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 = 125/65 (normotensive), T= 36.4°C (afebrile), 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 & History Inspection Palpation Percussion Auscultation Interpretation

Skin Skin color: jaundice in the Skin temperature: Uniform; Hepatitis produces jaundice,
extremities within normal range which is a yellowing of the skin,
- Patient is allergic to nail beds, and whites of the
erythromycin (rashes). eyes, as well as light feces and
black urine. . The accumulation
- Patient is anemic of a greenish–yellow material
(Hb=108; Hct=0.32) (known as bilirubin) in the
blood and tissues of the body
causes this (Dr. Mandal, 2019).

Nails Nail beds are yellowish Hepatitis produces jaundice,

which is a yellowing of the skin,
- Patient has history of nail beds, and whites of the
cholecystectomy. eyes, as well as light feces and
black urine. . The 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 over the Thickness or thinness of Not Applicable Not Applicable Normal Findings
No history of any hair scalp: Evenly distributed hair: Thick hair
disease ( Dillon Health Assessment,
 2006).
Texture & oiliness: Silky
and resilient hair

Presence of infections or
infestations: No infection or
infestation

Head Size, shape and symmetry: Not Applicable Not Applicable Not Applicable Normal Findings (Dillon,
Rounded, smooth skull 2006).
contour .

Absence of nodules and

masses

Facial features: Symmetric/

slightly asymmetric

Symmetry of facial
movements: Symmetric
facial movements

Ears Auricles (color, symmetry, Not Applicable Not Applicable Not Applicable Impaired excretion of urinary
and position): Grayish- pigments (urochromes) as
bronze color (sallow); well as the presence of
symmetrical; aligned with anemia due to lack of
outer canthus of eye erythropoetin being produced
(Pietrangelo, 2019)..
Client’s response to normal
voice tones: normal voice
tone audible

Body Parts & History Inspection Palpation Percussion Auscultation Interpretation

Eyes Sclera: Icteric Icteric sclera refers to the
Palpebral conjunctiva: Pink yellowing of the white area of
- Patient has history of your eye, which is a sign of
cholecystectomy. jaundice. Jaundice can be
caused by a number of
- Patient is anemic illnesses, including disorders
(Hb=108; Hct=0.32) with the liver, pancreas, or
gallbladder (Griff, 2020).

Mouth and Throat Outer and inner lips for Not Applicable Not Applicable Not Applicable Due to excessive dryness,
symmetry of contour, color decrease hydration and
and texture: Pallor, impaired circulation(Dillon,
fissures and dryness 2006).

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 (Dillon,
abnormal swelling or 2006).
masses: Muscle equal in
size; head centered

Enlargement of lymph
nodes: Lymph node not
palpable

Breasts Breasts are asymmetrical. No lump and masses noted Not Applicable Not Applicable Normally, Breasts are
No lesions noted asymmetrical, and non-
tender.
(Dillon, 2006)

Thorax and Back Chest expansion are Clear breath sounds. Atrial fibrillation (AFib) is
(cardio-pulmo) symmetrical. Weaning noted the most common problem
 during expiration. with your heartbeat's rate or
- Patient has history of rhythm. The basic cause of
asthma and smoking. AFib is disorganized signals
that make your heart's two
-noted atrial fibrillation upper chambers (the atria)
(11/30); ECG (12/1): left squeeze very fast and out of
atrial enlargement, sync (Dillon, 2006).
leftward deviation

- Hematology – anemia
(Hb=108; Hct=0.32)

• Respiratory – weaning

Body Parts & History Inspection Palpation Percussion Auscultation Interpretation

Abdomen Protuberant No masses palpated. Tympanitic sound Bowel sounds: 5 clicks per Protuberant abdomen is a
Tenderness upon palpation minute (normoactive). condition in which the
- Patient has epigastric abdomen becomes unusually
pain with a rate of 6/10, convex due to inadequate
and right upper quadrant muscular tone or extra
tenderness. subcutaneous fat. In the case of
the patient, his diet consists
- Patient is an occasional primarily of meat, fatty meals,
alcohol beverage and soda, all of which are high
drinker. in fats and contribute to his
obesity (Driscoll, 2020).
- Patient’s usual diet:
prefers meat, fatty foods,
and soda.

 Genito-Urinary Urine color light Yellow Not able to assess Not Applicable Not Applicable It contains RBCs, WBCs and
– Creatinine=1.68  Transparency is turbid pus which indicates
GFR of 38.4 (CKD malfunction of the kidneys to
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 skin,
turgor. nail beds, and whites of the
Height: 152 cm eyes, as well as light feces and
Weight: 68 kg black urine. . The accumulation
of a greenish–yellow material
BMI: 29.4 (overweight) (known as bilirubin) in the
blood and tissues of the body
causes this (Dr. Mandal, 2019).

• Vitals Sign

BP:150/70 (at the ER), 125/65 (ICU)

T: 39.5oC (at ER), 36.4oC (ICU),

RR: 21cpm

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
and stent resistance profiles

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 o
f infection.

Erythrocytes 4.2-5.4 / mm3 3.24 “L” Result was below normal. This 

indicates alteration in erythro
poietin production secondary 
to renal malfunction.

Hemoglobin 11.0-15.0 / mm 9.5 “L” Result was below normal. This 

3 shows the decrease in the oxy
gen carrying capacity of the bl
ood secondary low hematocrit
..

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

3 showing anemia related to ins
ufficient RBC production.

Thrombocytes 150-450 / mm3 442 Normal.

Neutrophils 50-70 / mm3 89.200 “H” Result shows increased in nor

mal level, indicating bacterial i
nfection.

Lymphocytes 20.0-40.0 / m 55.00 “H” Result is above the normal r

m3 ange, indicating bacterial inf
ection.
Monocytes 0.0-7.0 / mm3 3.800 Normal.

Eosinophils 0.00-5.00 / m 1.200 Normal.

m3

Basophils 0.000-1.000 /  0.300 Normal.

mm3

Chemistry

CHEMISTRY: Normal value Result Analysis

7-20 111 mg/dl “H Result was above the nor

” mal range indicating rena
Urea Nitrogen l malfunction.

0.52-1.25 16.83mg/dl “ Result was above normal 

H” thus showing inability of t
Creatinine he kidney to excrete nitro
genous waste.

137-145 150 mmol/l “ Result shows an increase

H” d in normal level of sodiu
Sodium m, thus suggesting renal 
dysfunction.

3.5-5.1 6.2 mmol/l ” Result shows an increase

H” d in normal level of potas
Potassium sium, thus suggesting ren
al dysfunction.

2.5-4.5 12.9mg/dl ”H Result shows an increase

” d in normal level of phosp
Phosphorus horus, thus suggesting re
 nal dysfunction.
Calcium 1.12-1.32 1.08mmol/l ” Result shows an increase
H” d in normal level of calciu
m, thus indicating renal d
ysfunction.

Urinalysis

Result Analysis
Normal

Physical Color Light Yellow
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 whi
ch indicates malfunction of the kidney
s to reabsorb and filters.
Specific Gravity 1.010 Normal
Albumin +++    Increased albumin excretion is an in
dicative of increased

permeability of the filters of

kidney (glumerolus), and may

be caused by disease (diabetes, hype
rtension, lupus, infections, nephritis).
Sugar Trace High level of glucose and other sugar 
in the urine can be caused by advanc
ed kidney disease, impaired tubular re
absorption.
Pus cells 4-6/hpf There is presence of bacterial infectio
n as evidenced by presence of bacteri
a, pus cells and RBCs.

RBC 0-2/hpf
 Epithelial cells Many

Bacteria

Few

Ultrasound

Result
Findings:
Ultrasound show biliary dilatation with calculi, with or without 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

 Intravenous antibiotics to fight infection

 Vasopressor medications, which are drugs that constrict blood vessels and
help increase blood pressure.

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

 Insulin for blood sugar stability corticosteroids

 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.

NURSING CARE PLAN

1. Altered Renal Perfusion RT Glomerular Malfunction

2. Acute abdominal pain r/t obstruction/ductal spasm

3. Decreased Cardiac Output rt Alteration in heart rate, rhythm, and conduction

Assessment Nursing Diagnosis a Goals and Objectives Intervention Rationale Evaluation
nd Intervention
Subjective Cues: Nursing Diagnosis Goal: Facilitate the m Independent: After 8 hours of nur
: Altered Renal Perf aintenance of electroly sing intervention, G
   “Napapansin ko po  usion RT Glomerula te balance. oal met the patient 
maam habang umiihi p r Malfunction was able to:
o ako na yung ihi ko po  1. Establish rapport 1. To get the cooperat
ay kulay pula” ion of the patient and 
Objectives: SO.
Demonstrate partici
After 8hours of nursing  pation in his/her rec
Objective Cues: Inference: intervention the patient  ommended treatme
will be able to. 2. To obtain baseline  nt program.
Increase in Lab results  data.
(BUN, Creatinine -
2. Monitor and record vital 
16.83mg/dl “H”) loss of kidney excret signs and assess patient’s ge
ory functions Patient will demonstrat neral condition. Demonstrate behav
Edema e participation in his/ iour/lifestyle chang
her recommended trea es to prevent compl
Haematuria Impaired excretion o tment program. ications
f nitrogenous waste  3. Determine factors related 
product Patient will demonstrat
to individual situation and n 3. To assess causative 
e behaviour/lifestyle c
ote situation that can affect  and contributing fact
  hanges to prevent co
all body system. ors
Increase in Laborat mplications
T ory result of BUN, C
reatinine, Uric Acid 
Vital signs: Level.
4. Note characteristic of uri
ne: measure urine specific g
BP: 83/55 mmhg  
ravity.
Altered Renal Perfu
sion
4. To assess for hema
Temp:36.4 C turia and proteinuria 
and renal impairment
RR: 21 cpm .
PR: 88bpm
5.  Ascertain usual voiding 
pattern and Note presence, l
ocation intensity duration of  5. To compare with c
pain. urrent situation and 
may indicate pain on 
affected organ.

6. Monitor for dependent 6. To note the

generalized edema. degree of
impairment of renal
function.

7. Measure urine output

on a regular schedule and
weigh daily. 7. To assess renal
perfusion and
function.

8. Identify necessary
changes in lifestyle and
assist client to
incorporate disease
management to ADLs. 8. To promote
wellness and
prevent further
progression of
Dependent complications.

1.Administer medication
as ordered.

For faster recovery.

2. Monitor patients lab It is used to treat
result and chemistry the client’s disease
condition.

3. Refer to physician
about the prescribe diet 2. To monitor any
that is appropriate to the unusual
client abnormalities in
patient condition.

3. Diet is one of the

factors that can
help in patients’
recovery and avoid
any complication.
 Collaborative:

1.Coordinate with the 1. Good nutrition

nutritionist about the can aid in patients’
prescribed diet for the recovery.
patient.

Assessment Nursing Diagnosis and Interven Goals and Objectives Intervention Rationale Evaluation

tion
Subjective: patient d Acute abdominal pain r/t obstru Goals: To facilitate optimal acti Independent: After 4 hours of n
escribe pain as crush ction/ductal spasm vity: exercise, rest and sleep. ursing interventio
ing and intermittent l 1.Observe and docu 1.Assists in differentiating cause  n, goal met; the p
asting for 30 minutes Objectives: After 4 hours of n ment location, sever of pain, and provides informatio atient was able to.
, with radiation to th
ursing intervention the patient  ity (0–10 scale), and  n about disease progression and r
e back. Inference: character of pain (st esolution, development of compl Report pain is reli
will be able to.
eady, intermittent, c ications, and effectiveness of int eved/controlled.
Cholangitisis the most serious co olicky). erventions.
-Report pain is relieved/
mplication of gallstones and more  controlled. Pain is reduce fro
Objectives: difficult to diagnose. Itis caused b 2.Note response to  m 6/10 to 2/10.
y impacted stone in the common b medication, and rep
Guarding Behaviour owel duct, resulting in bile stasis,  -Pain is reduce from 6/10 to 2/ ort to physician if pa 2.Severe pain not relieved by rou Demonstrate use 
bacteremia and septicemia if left u 10. in is not being reliev tine measures may indicate devel of relaxation skills 
Facial mask of pain ntreated. It is more likely to occur  ed. oping complications or need for  and diversional ac
when an already infected -Demonstrate use of relaxation  further intervention. tivities as indicate
Pain scale was 6/10 skills and diversional activities  3.Promote bedrest, a d for individual sit
as indicated for individual situa llowing patient to as 3.Bedrest in low-Fowler’s positi uation
(+) Generalize weak tion. sume position of co on reduces intra-abdominal press
ness mfort. ure.
 4. Encourage use o
f relaxation techniqu
Vital signs: es. Provide diversio 4.Promotes rest, redirects attenti
nal activities on, may enhance coping.
BP:83/55 mmhg

Temp:36.4 C
.
RR: 21 cpm
PR: 88bpm 5.Control 5.Cool surroundings aid in
environmental minimizing dermal discomfort.
temperature.

6.Make time to
listen to and 6.Helpful in
maintain frequent alleviating anxiety and
refocusing attention, which can
contact with
relieve pain.
patient.

Dependent:

1. Maintain NPO
status, insert 1. . Removes gastric secretions
and/or maintain that stimulate release of
 NG suction as cholecystokinin and gallbladder
indicated. contractions.

2. Administer 2. For faster recovery. It is used

medication as to treat the client’s disease
condition.
ordered.

Assessment Nursing Diagn Goals and Objectives Intervention Rationale Evaluation

osis and Interv
ention
Subjective Cues Decreased Car Goals: To facilitate the  Independent: After 4 hours of nursing 
: diac Output rt  maintenance of regulator intervention, Goal met;t
Alteration in h y mechanism and functio 1.For patients with in 1.Fluid restriction decreases  he patient was be able t
 Patient verbaliz eart rate, rhyt ns. creased preload, limit  the extracellular fluid volume  o;
ed “ nahihirapan  hm, and condu fluids and sodium as  and reduces demands on the 
po akong humin ction secondar Objectives: ordered. heart.
ga” y to septick sh
ock After 4 hours of nuraing i 2.  Closely monitor flu 2. In patients with decreased  1.Patient demonstrates 
Objective Cues: ntervention the patient wi id intake, including IV  cardiac output, poorly functio adequate cardiac outpu
ll be able to; lines. Maintain fluid re ning ventricles may not toler t as evidenced by blood 
Noted atrial fibrilla striction if ordered. ate increased fluid volumes. pressure and pulse rate 
tion (11/30); ECG  Inference: and rhythm within norm
(12/1): 3. If chest pain is pre 3. These actions can increas al parameters.
Decrease Contr 1.Patient demonstrates ad sent, have the patient  e oxygen delivery to the coro
left atrial enlarge actability equate cardiac output as e lie down, monitor car nary arteries and improve pa 2.Patient exhibits warm
ment videnced by blood pressu diac rhythm, give oxy tient prognosis. Symptoms c , dry skin, eupnea with 
re and pulse rate and rhyt gen, run a strip, medi an also be manifestations of  absence of pulmonary 
leftward deviation hm within normal param cate for pain, and noti myocardial ischemia and sho crackles.
Ventricle dilate eters. fy the physician. uld be reported immediately.
Vital signs: s to increase co 3.Patient remains free 
BP:  83/55 mmhg ntractability fro 2.Patient exhibits warm,  4.  Place on a cardiac  4. Atrial fibrillation is commo of side effects from the 
m stretched mu dry skin, eupnea with abs monitor; monitor for d n in heart failure and can cau medications used to ac
Temp:36.4 C scle fibers ence of pulmonary crackl ysrhythmias, especial se a thromboembolic event. hieve adequate cardiac 
es. ly atrial fibrillation output.
RR: 21 cpm  
PR: 88bpm Increase ventric 3.Patient remains free of 
ular radius resul side effects from the med
ts in increase w ications used to achieve a
all tension dequate cardiac output.

Assessment Nursing Diagn Goals and Objectives Intervention Rationale Evaluation

osis and Interv
ention
Increase oxyg 4.Patient explains actio 5. Observe patient for u 5. This promotes the cooperatio 4.Patient explains actions and precautions t
en consumptio ns and precautions to t nderstanding and comp n of the patient in their own me o take for cardiac disease
n and increas ake for cardiac disease liance with medical regi dical situation.
e cardiac work men, including medicati
ons, activity level, and 
load
diet.

 
Cardiac output 
falls

  .
Increase symp
athetic outflow 
to increase he Dependent:
art rate and sy The failing heart may not be abl
stemic vascul 1.Administer oxygen th e to respond to increased oxyg
ar resistance erapy as prescribed. en demands. Oxygen saturation 
needs to be greater than 90%.
 
Stroke volume 
falls 2. Depending on etiological fact
ors, common medications inclu
2. Administer medicatio de digitalis therapy, diuretics, v
ns as prescribed, notin asodilator therapy, antidysrhyth
g side effects and toxici mics, angiotensin-converting en
ty. zyme inhibitors, and inotropic a
gents.
Decrease card
iac output
DRUG STUDY
 DRUG
DOSAGE
(Brand MECHANISM
(Recommen NURSING
name and OF INDICATION ADVERSE REACTION
CLASSIFICATION ded and RESPONSIBILITIES
Generic ACTION
Actual)
name)
Brand Pharmacological: Intravenous  Anterograde
The actions of  Monitor and
name: amnesia
benzodiazepines Indicated for promoting record patient
Versed Benzodiazepines  Euphoria
preoperative sedation, response to
such as  Ataxia
anxiolysis, anesthesia medication and
midazolam are induction, or amnesia.  Falls and
mediated level of sedation.
Generic Confusion in the
through the  Continuous
name: elderly
inhibitory cardiorespiratory
Therapeutic: CONTRAINDICATION:
neurotransmitter monitoring.
Midazolam  Thrombophlebiti
gamma- Caution is  Inspect insertion
Antianxiety s, thrombosis,
necessary for pregnant site for redness,
agents, aminobutyric acid pain, swelling,
individuals, children, and pain on
Anxiolytics, (GABA), which is and other signs
and individuals with injection
Anticonvulsants one of the major of extravasation
comorbid psychiatric
inhibitory conditions. Recommend during IV
 Hypotension
neurotransmitters Administration in elderly infusion.
ed: and tachycardia
in the central individuals and acutely  Monitor for
can occur with hypotension,
nervous system. ill patients requires
Intubated rapid especially if the
Benzodiazepines caution to prevent the
accumulation of active Patients, intravenous patient is
increase the 0.05–0.2 premedicated
metabolites. Extra administration.
activity of GABA, mg/kg/h by with a narcotic
precautions should be A higher dose
thereby taken in critically ill agonist
continuous can result in
producing a individuals as dose analgesic.
infusion midazolam  Monitor vital
sedating effect, accumulation can IV Induction infusion signs for entire
relaxing skeletal occur.
for General syndrome and recovery period.
muscles, and Anesthesia In obese patient,
respiratory
inducing sleep, Adult: half-life is
depression.
anesthesia, and IV prolonged during
amnesia. IV infusion;
Premedicate
Benzodiazepines therefore,
d, 0.15–0.25  Residual
bind to the duration of
mg/kg over hangover effect effects is
benzodiazepine 20–30 s, can happen with prolonged (i.e.,
site on GABA-A allow 2 min nighttime amnesia,
receptors, which for effect IV administration of postoperative
potentiates the midazolam, recovery).
effects of GABA which can  Observe for
Actual:
by increasing the overdose
continuous impair the
frequency of symptoms
infusion of cognitive and
 DRUG (Brand MECHANISM DOSAGE NURSING
name and OF INDICATION (Recommende ADVERSE REACTION RESPONSIBILITIE
CLASSIFICATION
Generic name) ACTION d and Actual) S
Brand name: Pharmacological:  Monitor
constantly while
Levophed Catecholamine patient is
receiving
norepinephrine.
Take baseline
BP and pulse
Generic name: Therapeutic: before start of
therapy, then
Norepinephrin Alpha and Beta q2min from
e Adrenergic initiation of drug
Agonist until stabilization
(Sympathomimetic occurs at
) desired level,
then every 5 min
during drug
administration.
 Observe
carefully and
record mental
status (index of
cerebral
circulation),
DRUG skin
(Brand MECHANISM DOSAGE temperature of
NURSING
name and OF INDICATION (Recommended ADVERSE REACTION
CLASSIFICATION RESPONSIBILITIES extremities,
Generic ACTION and Actual) and color
name) (especially of
Brand Pharmacological: Ampicillin is Indicated for the Recommended: Body as a  Instruct or educate theearlobes, lips,
Indicated to restore
name: bactericidal; it treatment of mild to Whole: Similar to those patient to take nail beds) in
BP in certain acute  Arrhythmias
Aminopenicillin adheres to moderate infections Systemic for penicillin G. ampicillin with a full addition to vital
hypotensive states
Unasyn bacterial due Norepinephrin
to E. coli, P. Infections Hypersensitivity (pruritus,  Convulsions
glass of water on an signs.
such as shock. Also  Chest
penicillin- mirabilis, enterococci,
e functions as urticaria, eosinophilia, emptypain
stomach (at Monitor I&O.
as adjunct in  Photophobia
a peripheral Urinary
treatment of cardiac Recommended
vasoconstricto  Blurred vision retention and
arrest. :
r by acting on  Restlessness kidney
alpha- CONTRAINDICATIO Adult:  Anxiety shutdown are
adrenergic N: IV Start with 8–  Tremors possibilities,
receptors. It is 12 mcg/min,  Pallor especially in
 binding Shigella, S. typhosa Adult: hemolytic anemia, least 1 h before or 2 h
Therapeutic: proteins, thus and other Salmonella, PO 250–500 mg interstitial after meals) for
Generic inhibiting nonpenicillinase- q6h nephritis, anaphylactoid maximum absorption.
name: Broad Spectrum bacterial cell producing N. IV/IM 250 mg–2 reaction); Food hampers rate
Anti-infective wall gononhoeae, H. g q6h superinfections. and extent of oral
Ampicillin synthesis. influenzae, absorption.
Sulbactam staphylococci and CNS: Convulsive
inhibits beta- streptococci. Actual: seizures with high doses.  Determine previous
lactamase,   2 g IV hypersensitivity
Skin: Rash.
an enzyme CONTRAINDICATION: reactions to
produced by SIDE EFFECTS: penicillins,
ampicillin- Hypersensitivity to  Diarrhea cephalosporins, and
resistant penicillin derivatives;  Nausea other allergens prior
bacteria that infectious  Vomiting to therapy.
degrades mononucleosis.
ampicillin.
 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 MECHANISM INDICATION DOSAGE ADVERSE REACTION NURSING

 (Brand
name and OF (Recommended
CLASSIFICATION RESPONSIBILITIES
Generic ACTION and Actual)
name)
Brand Pharmacological: Ceftriaxone Indicated Recommended: Body as a  Determine history of
name: is primarily treatment to Whole: Pruritus, fever, hypersensitivity
Third-generation bactericidal; it bacteremia, Moderate to chills, pain, induration reactions to
Rocephin Cephalosporin also may be and Severe at IM injection site; cephalosporins and
bacteriostatic. septicemia. Infections phlebitis (IV site). penicillins and history
Activity of other allergies,
depends on Adult: GI: Diarrhea, abdomin particularly to drugs,
Therapeutic: organism, CONTRAIN IV/IM 1–2 g al before therapy is
Generic tissue DICATION: q12–24h (max: 4 cramps, pseudomembr initiated.
name: Broad-spectrum penetration, g/d) anous colitis, biliary  Lab tests: Check
Antibiotic and dosage, sludge. culture and
Ceftriaxon and rate of Hypersensiti sensitivity tests
Urogenital: Genital
e organism vity to Actual: before initiation of
pruritus; moniliasis.
multiplication. cephalospori  1 g IV q12-24hr therapy and
It acts by ns and for 5-7 days SIDE EFFECTS: periodically during
adhering to related  rash therapy.
bacterial antibiotics;  nausea  Inspect injection sites
penicillin- pregnancy  vomiting for induration and
binding (category B).  upset inflammation. Rotate
proteins, stomach sites. Note IV
 dizziness
thereby injection sites for
 headache
inhibiting cell signs of phlebitis
wall (redness, swelling,
synthesis. pain).
 Monitor for
 manifestations of
hypersensitivity.
Report their
appearance promptly
and discontinue
drug.
 Watch for and report
signs: petechiae,
ecchymotic areas,
epistaxis, or any
unexplained
bleeding. Ceftriaxone
appears to alter
vitamin K–producing
gut bacteria;
therefore,
hypoprothrombinemi
c bleeding may occur

 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 : 

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https://www.ncbi.nlm.nih.gov/books/NBK537321/

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