NUR231: Nursing Science - Drug Therapy Case study - Assessment Answers

November 29, 2017
Author : Charles Hill

Solution Code: 1HJI

Question: Nursing Cases Study

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Nursing Cases Study Assignment

Case Scenario

This case study assignment is based on the theory and principles covered in lectures, tutorials and associated resources. It is designed to develop knowledge and problem-solving skills that apply to drug administration and management in complex health care settings.

Consider the patient Situation

Mr. Edward Hunter, an 89 year old widower, is now day 7 following his admission with end-stage pulmonary fibrosis, hypoxaemia (oxygen saturations 82% in the ambulance) and chestinfection. He has been under the care of the community nursing team who have providednursing support and home oxygen therapy. Mr. Hunter’s condition continues to deteriorate.He is on 15 litres oxygen via the non-rebreather mask to maintain oxygen saturations > 94%.His severe dyspnoea renders him immobile and barely able to eat. At night he becomes quiterestless and distressed by his breathlessness. Whilst in hospital he has been under the care ofthe palliative care team who prescribed Morphine elixir 2.0-2.5 mg PO PRN nocte toalleviate the distress associated with his dyspnoea.

Collect information

Mr. Hunter developed a fever of 38.0oC two days ago and has chills and bloody, jelly-likesputum. Culture and sensitivity on Mr. Hunter’s sputum specimen reveals Streptococcuspneumoniae and Klebsiella pneumoniae and he is diagnosed with hospital acquiredpneumonia. Mr. Hunter was previously prescribed Amoxycillin (Amoxicil, Alphamox) 500mgcapsules PO TDS and Clarithromycin (Clarac, Klacid) 500mg PO BD for his chest infectionand he has diarrhoea associated with the macrolide antibiotic therapy. Laboratory tests from astool sample confirm that he has Clostridium difficile (C.difficile) infection.

The Klebsiella pneumoniae infection poses a serious risk to Mr. Hunter of furtherdeterioration in lung function and of developing an empyema. Klebsiella infection is seen inelderly hospitalised patients who are already ill and immunocompromised and withunderlying chronic lung disease. Since Klebsiella demonstrates antimicrobial resistance - thebacterium is intrinsically resistant to Penicillins and can acquire resistance to Cephalosporins- Mr. Hunter is commenced on an aminoglycoside and is prescribed gentamicin IV infusion.

Identify problem/issue:

Question 1- Explain why Mr. Hunter has the ‘superinfection’ known as C.difficile anddescribe the nursing care required to contain this infection.

Question 2 - Explain how aminoglycosides work to combat infection and why plasma drugconcentrations of the aminoglycoside Gentamicin are monitored.

Question 3 – Relate what you know about how Gentamicin achieves its antimicrobial effect(ie. is antimicrobial efficacy dose-dependent or concentration-dependent) to explain theconsequences of a ‘missed’ dose or giving a ‘late’ dose in an antibiotic treatment regime.

Question 4 – What is the nurses’ role in ‘antimicrobial stewardship?’ Examine the research

literature in the USC library databases and choose at least 2 journal articles that discuss

antimicrobial stewardship (AMS) in order to identify the nurses’ role in improvingantimicrobial use in hospitals. Analyse the papers and summarise the main points.

Process information

Mr Hunter has had an indwelling urethral catheter in situ for 1 week. The catheter wasremoved 24 hours ago because urine was bypassing the catheter. He is now experiencingurinary frequency (<2hr) and pain on voiding. Mr Hunter asks if the catheter can bereinserted because of the fatigue and distress the ‘frequency of urination’ is causing.

Question 5. What is your assessment of Mr Hunter’s current problem?

Question 6. What pathology knowledge would help you to carry out your assessment? Whatdata would validate your decision?

Question 7. What would be the potential outcome(s) if Mr. Hunter’s condition remainsuntreated?

Establish and prioritise goals:

Question 8. Can you identify 2 short-term nursing goals to alleviate Mr. Hunter’s urinaryfrequency and pain on voiding?



Take action:

Question 9. Can you plan your nursing care to describe the nursing actions (pharmacologicaland/or non-pharmacological) you would implement to manage Mr. Hunter’s ‘frequency ofurination’ and associated fatigue? Give a rationale/justification for your decisions.


o Question 10a. What are the three most important things that you have learned fromthis scenario?

o Question 10b. What actions will you take into clinical practice as a result of yourlearning in this scenario?


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Answer 1

Mr. Hunter has been diagnosed with hospital acquired pneumonia. The diagnosis reveals infection of Klebsiella pneumoniae and Streptococcus pneumoniae. Previously he has been prescribed antibiotics such as Amoxycillin and Clarithomycin. Currently he is suffering from the chest infection along with diarrhea problem.

Mr. Hunter has been detected with secondary infection of Clostridium difficile bacteria. The superinfection poses risk for deterioration of lung function. It is evident that chances of infection increase among aged people those who are having immunocompromised system. This leads to antimicrobial resistance. Length of the hospital and length of the previous antimicrobial therapy both plays an important role and sometime, act as risk factors that gives raise to secondary infection. It is evident from the case study that Mr. Hunter, 89 year old person, taking antibiotic therapy, is now admit in the hospital from a week. Age, course of medicines, and hygiene practices being followed in the hospital could be the risk factors for his ill health. In most of the cases, infection of Clostridium difficile occurs after antibiotic therapy. It is the major cause of diarrhea among the older patients (Saidel-Odes, Borer & Odes, 2011). Use of broad spectrum antibiotics reduces secretion of gastric juice that weakened the immune system. Antibiotics have an impact on gastric activities by suppressing the gastric juices and overall, affect host defense mechanism. Clostridium difficile bacterial infection is associated with reduced gastric acidity and disruption of normal flora of the intestine which occurs due to heavy use of antibiotics (Biswal, 2014). Mr. Hunter has been exposed to antibiotics which is probably leading for secondary infection of Clostridium difficile.

The nursing professionals must be knowledgeable to identify the signs and symptoms of Clostridium difficile. They should be able to understand their role in preventing infection and the related precautions. Nurses are required to follow the same protocol as they do for any patient of diarrhea, gastro intestinal disease or contagious illness. The nursing staff must be able to assess the patient’s condition such as any associated complications or adverse events. They should monitor stool output, abdominal firmness, and patient’s nutrition. As Mr. Hunter is immobile and unable to eat so a nurse has to take care of both along with maintaining proper hygienic condition. Nurses should clean the patient’s hand with soap and should avoid the use of topical agents such as wipes as they can affect patient’s skin integrity. Though medical treatment is prescribed by the medical doctors but nurses must be aware of the treatment algorithms to effectively coordinate with the medical team. They should be able to assess the requirement of electrolytes and fluids.

Answer 2

Aminoglycosides are known as broad spectrum antimicrobial agents with their properties of treating life threatening infections. They have become the important therapy line drugs to prevent infection related health issues. Medical professionals are recommending these drugs on frequently basis. These are often given through IV (intravenous) as they are absorbed poorly by oral mode of administration. Aminoglycosides are absorbed effectively through pleural cavity and peritoneum. These agents are basically involved in inhibition of protein synthesis. Evidences are available to show that Aminoglycosides bind with 30S subunit of the bacterial ribosomes irreversibly. Microbes allow antibiotics to enter into the system through their porins situated in their outer membrane. Then the agents are transported into the cytoplasmic membrane through an oxygen dependent mechanism. There, Aminoglycosides disrupts the function of ribosome apparatus of the microbes. These agents interfere with the elongation of polypeptide chain by preventing activity of peptidyl transferase RNA. Binding with the 30S subunit disturbs the proofreading process that is needed to assure the accuracy during the translation procedure. Aminoglycosides possibly increase the premature termination rate of protein synthesis (Yeng & Ye, 2010).

It is very important to monitor the drug concentration in plasma of gentamicin (Aminoglycoside). Plasma concentration is used for detection of any toxicity, optimization of patient treatment & management and improvement in health outcomes. Monitoring assists for dosage individualization and plays a role in the context of the patient’s health. For example, if a drug’s concentration is lower than the target range but is not experiencing diarrheal symptoms so maintaining the dosage concentration within the normal range is not required (Moulds & Jeyasingham, 2010).

Answer 3

Gentamicin is an example of an Aminoglycoside that acts by preventing the function of bacterial protein synthesis. The spectrum of activity of Gentamicin has defined as broad and has bactericidal effect. Gentamicin effectively creates fissures within the membrane of the bacterial wall. It is particularly effective against gram negative bacteria and certain gram negative bacterial species (Yeng & Ye, 2010). It has been also found effective against several resistant bacteria. Basically it is used to treat severe abdominal infection, urinary tract infection, bacteremia etc. Resistance is the key issue with the prolonged use of Aminoglycoside. Risk of toxicity is associated with high volume of Gentamicin therefore, lowering the use of the drug can be the way out to reduce the risk. It shows concentration dependent bacterial killing effect that also helps in decreasing the toxic effects. During a given period of time, bactericidal activity increases in proportion with its concentration. Daily single dose of Gentamicin is effective and safe while multiple dosing is preferred for certain situations. Negative consequences may occur in case of any missed dose or late dose of an antibiotics such as Gentamicin.

Answer 4

1st Journal article – Successful treatment depends upon monitoring by done the nursing staff. Health outcome increases due to management and assessment of a patient’s health. Nurses’ contribution can have an impact on development of resistance against microbes within the hospital setting. The management practices of promoting antimicrobial procedures have not included nurses that has limited the associated positive health outputs. For a successful antimicrobial stewardship program, a concrete decision making is needed in this regard. Nurses are involved in patient care most of the time so they must be encouraged to provide services involving antimicrobial practices. Their role must contextualized in an order to decrease the hospital acquired infection rate. Such initiative can truly impact the overall hospital services. The paper highlights the role of nurses in controlling the cases of antimicrobial infection as inappropriate use of antimicrobials is resulting into increased hospital acquired infection issues (Edwards et al, 2011)

2nd Journal Article – Nurses plays in important role in reducing the burden of infection in the hospital. The problem is associated with the workload of nurses as they are involved in several activities. This is hampering their quality work and resulting into higher number of cases of the microbial infection. The article depicts that 10% reduction in workload can probably prevent thousand number of infections and produces high quality results. The hospital practices should include the role of nurses in controlling the infection rate by providing a supportive environment to them. The hospital climate and relationship with the colleagues both are an important aspect of care and treatment. Hence it is required to make some changes within hospital policies and programs (Potera, 2012).

Answer 5

At present, Mr. Hunter is suffering from various health issues. He has been found with the chest infection and pulmonary fibrosis (final stage). Despite providing continuous nursing care and support, his health condition is deteriorating. He is having difficulty in breathing which becomes more intense during night time and leaves him under heavy stress. Though Morphine has been given to control his distress and anxiety level. Diagnosis reports that he is having hospital acquired infection of pneumonia. Mr. Hunter’s health condition is not stable yet because of microbial infection. His health is at higher risk of getting secondary infection which mostly occurs among older people with diminished immunity. Age, hospitalization and use of broad spectrum antibiotics have all contributed for his health condition. He is on a macrolide antibiotic therapy before admitting to the hospital and this is one of the main contributing factor for his diarrhea. It is confirmed from the laboratory results that he has received the secondary infection of Clostridium difficile. Along with this, it is possible that his condition might worsen due to severe lung infection as he is already having chest infection because of Klebsiella pneumoniae. Development of antimicrobial resistant poses a threat to the patient as same with Mr. Hunter. That’s the reason that he has administered gentamicin and aminoglycoside. He has complained of pain on voiding and an urge of frequent urination. It is possible to relate the urination problem with the secondary infection as urinary infection is the leading cause of higher urination rate. Distress could also be related with the urination problem.

Answer 6

The pathology knowledge of secondary microbial infection would be an added advantage for the medical team providing treatment and medications. It is essential to have a clear understanding of opportunistic infection as it increases with length of the hospital stay (Mehta et al, 2014). The team must be aware of the virulence factors, transmission ways, antibiotic resistance, species related diseases, adherence, toxins and also pathogenesis of infection. Knowing resistance mechanism could help for the better treatment which in turn will improve the health outcomes. Extensive knowledge of the pathology provides a basis for the drug selection. The treatment decision will depend upon the following key information which must be collected before commencing further actions –

  • Prior use of antibiotics
  • Symptoms associated with infection and secondary infection
  • Oxygen saturation
  • Urination rate
  • Anxiety level
  • Lung infection
  • WBC Count
  • Antimicrobial resistance
  • Breathing rate
  • Trauma related information

Answer 7

It is highly likely that serious health consequences may occur if Mr. Hunter’s health is not treated on time with proper medications. It is possible that Mr. Hunter can experience severe lung infection as he is already experiencing chest infection. Infection can spread within the pleural cavity that can result into collection of pus within the pleural space. Building up of pus creates pressure on lungs. Bacterial pneumonia is one of the main risk factor for pus formation in lungs. It can lead for dry cough, intense chest pain, fever, discomfort, shortness of breath, sweating etc. All these mentioned risk factors can contribute for higher level of stress or anxiety. The situation can further complicate as pneumonia can lead to reduced lung activity and thickening of pleura (Broaddus & Light, 2016).

Another possibility could be the development of antibiotic resistance. Mr. Hunter is already taking antibiotic drugs to control the primary infection of Streptococcus pneumoniae and Klebsiella pneumoniae. Antibiotic resistance is an incurable illness that puts heavy mental pressure on the patient. This can lead for more serious side effects, increased suffering, and increased treatment cost. Elderly people are at higher risk of antibiotic resistance. That can also expose a person for more bacterial infections and weakened immunity.

People at higher age are at risk of getting urinary tract infection. Mr. Hunter is having a problem of frequent urination that could be related with the primary bacterial infection and the level of anxiety. An increased urge of urination might be related with distress or anxiety. E.coli can cause urinary tract infection in the form of secondary infection. It could be revealed though laboratory diagnosis. If left untreated, it can damage kidney functions and activity.

Answer 8

The short term goals of the nursing plan would include the following activities (Ribeiro, 2015) -

  1. They will monitor the urine volume or output within 24 hours of the admission. Nurses should advise the patient to adhere to drug regimen prescribed by the doctor that will help to reduce his anxiety level. They must provide an adequate information to the patient which is needed to get his support for the treatment.
  2. Nurses should follow aseptic techniques during catheter insertion in an order to prevent cross infection that otherwise could lead for frequent urination problem. Following aseptic procedure would probably reduce the chances of secondary infection in urinary tract.

Answer 8

Nursing goal Nursing action
To educate the patient about the importance of drug adherence along with monitoring of urine output Nurses can provide complete education to the patient about the health consequences of not taking the proper medication.

Rationale - Antibiotics are the preferred choice to treat urinary problems. The dosage forms depend upon the urinary volume. Drug dose must be adjusted along with the change in urine output. Hence a nurse should advise the patient to monitor his urine volume for the treatment purpose (Ribeiro, 2015).

To follow aseptic procedures to reduce the chances of infection It would reduce the rate of secondary infection.

Rationale – Un septic procedures give raise to higher chances of secondary infection among elderly patient. This in turn increases the urine frequency, hospital stay, heavy treatment of antibiotics and stress level. Therefore all the risk factors can be reduced by adopting aseptic practices (Ribeiro, 2015).

Answer 10a

From the case study analysis, I have learned the following points-

  1. Hospital acquired infections are presenting higher risk for both the hospital and the patient. If patient is not treated properly then it could lead for serious health consequences. It is important to pay attention to hospital policies regarding infection control and preventive measures. The hospital should review its existing control policy and the related rate of infection. If it is found that the rate has increased then the hospital management must take actions by reviewing the current health situation. Evidence based practices could be used to improve the hospital functioning (Brown & Edwards, 2015)
  2. Role of nurses becomes important for treating antimicrobial resistant. They must be provided enough knowledge so that can handle the patients more confidently. This would probably assist to reduce the burden of related cases. Nurses should be trained in this regard and it is advisable to give them practical knowledge during their training time period. They should be able to understand the role of disease management and use of drugs (Bryant & Knights, 2015)
  3. Another learning is related to continuous use of antimicrobial therapy. This is the main factor to increase the cases of secondary infections within the hospital premises. If the associated symptoms are stable or not increasing anymore then the medical staff must take an action for the use of heavy antibiotics. As this also leads for long hospital stay and higher treatment cost.

Answer 10b

Based upon the experience of this case study, I would like to follow aseptic techniques very strictly so that unnecessary hospital stay can be avoided which otherwise creates financial and mental pressure for the patient and the family. Nursing staff must be kept informed about the aseptic practices of the hospital. They must be aware of the drug administration, dosage forms, side effects etc (Tiziani, 2013). This will help to achieve the targets of the treatment plan in an order to improve the health status of the patient. Hospital must include about the major therapies, and their role in preventing infection. Patient’s education will also be considered as an important aspect of the treatment and care.

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