CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF NURSING
The FIrst Nursing School in the Philippines, 1906
Jaro, Iloilo City, Philippines

Case Presentation

In Partial Fulfillment of the Requirements in

Related Learning Experience

Medical-Surgical Ward

Presented To:

Prof. Mark Clinton J. Layson, RN

Clinical Instructor

Submitted By:

Calinauagan, Nestle
BSN 4-B
 Patient Information

Patient: P.C
Medical Diagnosis: Metabolic Encephalopathy secondary to Urosepsis

DRUG STUDY

Mechanism of Indication/ Nursing

Action Contraindication Responsibility

Generic Name: Indications:

Piperacillin/Tazo The Piperacillin/tazobactam is Watch for seizures; notify physician
bactam combination of indicated to used as an immediately if patient develops or increases
piperacillin and seizure activity.
empirical treatment for
Brand name: tazobactam
Piptaz provides urosepsis, which is a severe
Monitor signs of pseudomembranous colitis,
synergistic urinary tract infection that including diarrhea, abdominal pain, fever, pus
Classification: activity against has spread to the or mucus in stools, and other severe or
Beta-lactam a wide range of bloodstream causing prolonged GI problems (nausea, vomiting,
antibiotics bacteria systemic symptoms. heartburn).
commonly
implicated in Monitor signs of allergic reactions and
Dosage:
urinary tract anaphylaxis, including pulmonary symptoms
4g q8h IV
infections and (tightness in the throat and chest, wheezing,
sepsis, cough dyspnea) or skin reactions (rash,
including pruritus, urticaria).
Escherichia
coli, Klebsiella Assess muscle aches and joint pain
pneumoniae, (arthralgia) that may be caused by serum
Proteus sickness.
mirabilis,
Enterococcus Monitor signs of blood dyscrasias such as
faecalis, and leukopenia and neutropenia (fever, sore
other throat, signs of infection) or thrombocytopenia
Gram-positive (bruising, nose bleeds, and bleeding gums).
and
Gram-negative
organisms.

Mechanism of Action Indication Nursing

 Responsibility

Generic Name: Exhibits bactericidal Indicated for patients with Watch for seizures; notify physician
Meropenem action against most bacterial infections immediately if patient develops or
Gram-positive and specifically patients with increases seizure activity.
Brand name: Gram-negative, intra abdominal and pelvic
Merrem resulting to cell death infection
Assess respiration, and notify
Classification: physician immediately if patient
Anti-infective; exhibits any interruption in respiratory
carbapenem rate (apnea) or other signs of
antibiotic respiratory failure (rapid labored
breathing, cyanosis, confusion,
Dosage: irritability, sleepiness, headache,
1g q8h IV oxygen desaturation).

Monitor signs of pseudomembranous

colitis, including diarrhea, abdominal
pain, fever, pus or mucous in stool,
and other severe or prolonged GI
problems (nausea, vomiting,
heartburn). Notify physician or nursing
staff immediately of these signs.

Monitor signs of allergic reactions and

anaphylaxis, including pulmonary
symptoms (tightness in the throat and
chest, wheezing, cough dyspnea) or
skin reactions (rash, pruritus,
urticaria). Notify physician or nursing
staff immediately if these reactions
occur.

Assess dizziness that might affect gait,

balance, and other functional activities.
Report balance problems and
functional limitations to the physician
and nursing staff, and caution the
patient and family/caregivers to guard
against falls and trauma.

Monitor injection site for pain, swelling,

and irritation. Report prolonged or
excessive injection site reactions to
the physician.

Instruct children and family/caregiver

to report signs of thrush and
moniliasis, including painful, creamy
white lesions on the tongue and inside
the mouth.

Instruct patient and family/caregivers

to report other troublesome side
effects such as severe or prolonged
headache, skin problems (rash,
itching), or GI problems (nausea,
vomiting, diarrhea, constipation).
Generic name Mechanism of Indication Nursing
Action Responsibility

Generic Name: Lactulose works by Lactulose is used to Assess patient for abdominal
Lactulose acidifying the colonic manage acute episodes distention, presence of bowel
contents, trapping of hepatic sounds, and normal pattern of bowel
Brand name: ammonia in the function.
encephalopathy, helping
Lilac colon, and
promoting its to rapidly reduce Assess color, consistency, and
Classification: excretion in the ammonia levels and amount of stool produced.
Osmotic stool. Lactulose also alleviate neurological
Laxative alters the colonic symptoms such as Assess mental status (orientation,
microbiota, favoring confusion, level of consciousness) before and
Dosage: the growth of disorientation, asterixis periodically throughout course of
5mL Syrup beneficial bacteria therapy.
(flapping tremor), and
that metabolize
ammonia into impaired Assess for signs of electrolyte
non-absorbable consciousness. imbalances, dehydration, or fluid
forms. overload, especially in patients with
Lactulose is also used hepatic encephalopathy or renal
as a maintenance impairment.
therapy to prevent the
Provide education to the patient and
recurrence of hepatic
family members about the purpose
encephalopathy in of lactulose therapy, including its
patients with chronic mechanism of action and expected
liver disease, effects.
particularly those with
cirrhosis. By promoting Caution patients that this medication
may cause belching, flatulence, or
regular bowel
abdominal cramping. Health care
movements and professional should be notified if this
reducing ammonia becomes bothersome or if diarrhea
levels, lactulose helps occurs.
to prevent the buildup of
neurotoxic substances Emphasize the importance of
in the bloodstream. maintaining adequate hydration
while taking lactulose to prevent
dehydration and electrolyte
imbalances.
 Actual Nursing Diagnoses

1. Impaired body defense mechanism related to sepsis as evidenced by generalized body

weakness, GCS 13, disoriented, mild confusion, positive for both gram-negative bacilli and
gram-positive, neutrophil count 81 (50-70), and 12 mg/dl C-reactive Protein

2. Acute Confusion related to metabolic encephalopathy as evidenced by disorientation, impaired

attention span, and fluctuating level of consciousness.

3. Altered level of consciousness related to increase level of ammonia secondary to urosepsis as

evidence by mild confusion, GCS 13, disorientation, slurred speech and generalised body
weakness

Nursing Care Plan

Assessment Nursing Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention

Subjective Impaired body Short Term: Independent Independent: Goal: MET

Cues defense After 24 hours Short Term:
-Generalized mechanism of nursing -Monitor Vital -Continuously After 24 hours of nursing
body weakness related to intervention, Signs: monitor vital intervention, the patient
sepsis as the patient will signs, was able to:
evidenced by be able to: including
generalized temperature, -Demonstrate stable vital
Objective body -Demonstrate heart rate, signs in within normal
cues: weakness, stable vital respiratory parameters
-GCS 13 GCS 13, signs in within rate, and blood
-Disoriented disoriented, normal pressure, to
-Mild confusion mild parameters detect signs of -Restored GCS score of
-positive for confusion, sepsis 15 indicating full
both positive for progression or consciousness and
gram-negative both -Restored septic shock. orientation to person,
bacilli and gram-negative GCS score of -Monitor for place, and time
gram-positive bacilli and 15 indicating signs of -Deterioration
-neutrophil gram-positive, full deterioration of of a clinical -Exhibit Alertness,
count 81 neutrophil consciousness the condition or condition or oriented, and able to
(50-70) count 81 and orientation failure to failure to participate in discussions
-12 mg/dl (50-70), and to person, improve with improve with coherently without signs
C-reactive 12 mg/dl place, and time therapy. therapy may of confusion
Protein C-reactive reflect
Protein -Alert, inappropriate Long Term:
oriented, and or inadequate
able to antibiotic After 3-5 days of nursing
participate in therapy or intervention, the patient
discussions overgrowth of was be able to:
coherently resistant or
without signs opportunistic -Demonstrates increased
of confusion organisms. strength and ability to
-Note perform activities of daily
Long Term: temperature - Hypothermia living
trends and is a grave sign
After 3-5 days observe for reflecting an -Neutrophil count returns
of nursing shaking chills advancing to within normal range
intervention, and profuse shock state, (50-70%) on complete
the patient will diaphoresis. decreased blood count (CBC)
be able to: tissue analysis
perfusion, and
-Demonstrates failure of the -CRP level decreases to
increased body’s ability to within the normal range
strength and mount a febrile (< 10 mg/dL) on repeat
ability to response. laboratory testing.
perform
activities of -Assess Urine -Exhibit absence of new
daily living Output -Monitor urine signs of infection
 output closely
-Neutrophil to ensure
count returns adequate renal
to within perfusion and
normal range identify signs
(50-70%) on of acute kidney
complete blood injury (AKI) or
count (CBC) renal failure
analysis early.
-Encourage
-CRP level Hydration -Encourage
decreases to adequate fluid
within the intake, unless
normal range contraindicated
(< 10 mg/dL) to promote
on repeat urinary flow
laboratory and flush out
testing. infectious
-Maintain sterile
-Exhibit technique when -Follow strict
absence pf changing aseptic
new signs of dressings, technique
infection suctioning, and during catheter
providing site care and
care, such as secure the
an invasive line catheter to
or a urinary prevent
catheter. displacement,
which can
introduce
pathogens into
the urinary
tract.
-Monitor
Urinary -Regularly
Catheter Output assess urinary
catheter output
and inspect the
urine for color,
clarity, and
presence of
sediment or
blood.

-Promote -Encourage
Mobilization early
mobilization
and frequent
position
changes to
prevent
pressure
ulcers.

-Provide -Address the

Comfort patient’s
Measures discomfort or
pain
associated
with urinary
symptoms or
interventions,
such as warm
compresses or
positioning, to
alleviate
discomfort and
promote
relaxation.

-Maintain Strict -Implement

Infection rigorous
Control infection
Measures control
 practices,
including hand
hygiene and
adherence to
aseptic
techniques
during
procedures
and patient
care activities.

-Educate -Provide
Patient and education to
Family the patient and
family
members
about urinary
sepsis,
including signs
and symptoms,
importance of
adherence to
treatment, and
strategies for
infection
prevention.
PATHOPHYSIOLOGY