A significant risk associated with the use of these medicines includes nephrotoxicity due to administration of hydrocortisone and antibiotics causing the urea and creatinine levels to increase. Acute kidney damage is characterized by increase in creatinine and an overall poor urine output (Rhodes et al., 2017,p.308). Mr Laurent appears to already experience renal complications as is evident by the increase in the urea and the creatinine level. Sepsis, dehydration and blood loss are all attributed to the cause of kidney malfunctioning (Sorli et al., 2013,p.381). In relation to the case study it can be said that the client is tachypnoeic and a heart rate of 112 beats per minute with raised body temperature that suggests the development of the initial symptoms of sepsis (Australian Sepsis Network, 2018; Daniels, Inada-Kim, Saifuddin, Nutbeam, & Edward, 2018) and contribute to the causes of kidney damage. According to (Davenport, Khalatbari, Cohan & Ellis, 2013, p.93) nephrotoxicity occurs when the process of excretion and elimination of toxins are disturbed due to the impaired kidney function. Drugs that cause nephrotoxicity elicit an inflammatory response affecting the glomerulus and proximal tubules surrounding the cell structures and then subsequently break down the renal tissues (Sorli et al., 2013,p.380). In general, it has been stated that drugs that inhibit prostaglandin, hinder arterial expansion (Rhodes et al., 2017,p. 363). In case of using ACE inhibitors, this leads to glomerular nephrotoxicity (Sorli et al., 2013,p.385). Furthermore, ACE inhibitors may make the patient susceptible to renal hypoperfusion due to the inhibited trigger of efferent arteriolar resistance (Davenport, Khalatbari, Cohan & Ellis, 2013,p.97). This in turn, causes a catastrophic reduction in the GFR and glomelular capillary pressure (Rhodes et al., 2017,p.345). In particular, intravenous antibiotics such as B-lactams also cause drug-related kidney toxicity (Sorli et al., 2013,p.382). The mitochondria in the renal tubules take the brunt of the damage as a result of the release of free radicals causing oxidative stress eventually leading to cytoxicity (Sorli et al., 2013,p.381).
The second major risk related to the use of medications is the difference in the blood sugar levels. Although there has been no traces of blood sugar recorded in the case study, as a type 2 diabetic indication on the levels of insulin and biguanides, the medications he is on could affect the development of a hyper or hypoglycaemic event. Due to critical illness, Mr Laurent has a series of compensatory mechanisms accounting for his current state. Davenport et al. (2013,p.97) states that Metformin is not likely to be administered to patients with respiratory failure, experiencing symptoms of dehydration, sepsis, tissue hypoxia or acute injury due to the associated damage it can cause. These specific conditions may all be relevant in the client’s case. Furthermore, Lantus is reported to interact with other diabetic medicines and ACE inhibitors which may boost the hypoglycaemic effect (Sorli et al., 2013,p.380). On the contrary, salbutamol and corticosteroids oppose the lowering of blood sugar levels (Davenport et al., 2013,p.95), antagonizing the imbalance in achieving a stable blood sugar level.
To prevent the risks associated with the above factors, monitoring of the urea and creatinine levels, GFR and the urine output is necessary. As mentioned before, Mr. Laurent is experiencing acute kidney damage. The medical team and nurses should consider medication dosing, route and length of drug exposure to avoid any further damage of the kidney function (Glowacki, 2015,p.40). Therefore, a major consideration in case of Mr. Laurent requires close monitoring of the renal function including urea, creatinine, electrolytes, particularly sodium and potassium levels (Berdot et al., 2013,p.11). Hydration measures should be carefully monitored including the input and output and administration of IV levels. Documenting a fluid balance chart of the above measures will ensure that appropriate amounts of fluid are provided and eliminated accordingly (Mentes & Kang, 2013,p.16). Although fluid administration has been shown to enhance kidney protection, patients may experience elevated central venous pressure and even fluid overload, which is associated with acute kidney malfunctioning (Mentes & Kang, 2013,p.16). With decreasing urine output, fluid retention may occur which can increase the pressure on the kidneys through elevated blood pressure and can lead to cardiac failure (Graan, Botti, Wood & Redley, 2016, p.167). ECG’s can be conducted to ensure that heart rhythm is monitored especially in the case of hyperkalaemia (Barr et al., 2013,p. 269). Measuring clinical observations is an important aspect with respect to any abnormal vital signs. Any abnormality must be escalated as per the hospital protocol. An increase in respiration rate for example could possibly indicate worsening fluid status or metabolic acidosis (Barr et al., 2013.p.267). Monitoring blood sugar levels along with ketones, is a primary responsibility for the RN (Boyd & Sheen, 2014,p.36). Furthermore, the nursing team should discuss closely with the doctor about the indications and whether the patient can resume their regular medications or not, depending on the patients’ clinical condition (Poole,2014,p.15). The patient may develop higher temperature and may feel nauseous. Additionally, he is in respiratory distress with tachypnoea and lower oxygen saturations, which consequently means that the patient will not be tolerating any food, and perhaps oral medications too, which will further affect his blood sugar levels (Glowacki, 2015,p.35).
There are multiple reasons accounting for medication errors in the healthcare system. The 7 Rights of Medication Administration is a safety measure implemented in nursing practice (Poole, 2014). Extending from the ‘Rights of Medication Administration’, checking the drug effect on a patient is vital as this process is undertaken to ensure that the patient’s clinical conditions improve (Graan, Botti, Wood & Redley, 2016, p.168). To highlight this point, the patient with an asthma induced wheeze and chest tightness with cardiac-related causes ruled out who is undergoing salbutamol therapy should be assessed for the efficacy of the medication administration. To ensure safety and acting within the relevant legal policies, Nursing and Midwifery Code of Conducts, guidelines and procedures to fulfill legal and ethical responsibilities is a necessity. Following hospital and ward policies act as safeguard policies for the nurse and patient. Standard 4, the ‘Medication Safety Standard’ in the National Safety and Quality Health Service Standards (NSQHS) demonstrates multiple processes involved in avoiding and reducing harm to the client during the process of medication assistance (Australian Commission on Safety and Quality in Health Care, 2017). After handover, the nurse may check the patient medication history as recorded during clinical documentation procedure to ensure that the patient does not have allergies or adverse reactions which may not have been recorded on the medication chart (Australian Commission on Safety and Quality in Health Care, 2017). Communicating with patients or with a caregiver in terms of understanding and thoroughly discussing the medication list is of high priority to ensure that there is no confusion and the patient is enlightened about their treatment and care process (Australian Commission Safety and Quality in Health Care, 2017). The factors that lead to medication errors are multi-faceted. Boyd & Sheen (2014) stated that nurses encounter frequent intrusions in the workplace while administering patient-care from colleagues and superiors, coupled with distractions in their surrounding clinical environment which contributes to adverse medication errors. There is an overwhelming incidence of medication errors, particularly with intravenous antibiotic administration (Engelbrecht, Wood & Cole-Sinclair, 2013, p. 399). Moreover, heavy workloads, general inattentiveness of staff tending to medications lacking in experience or knowledge can be associated to some of the major causes of these errors (Berdot et al., 2013,p.112). The notion of ‘double-checking’ medications is an informal yet common practice that nurses perform to reduce errors and harm to the patient (Poole, 2014,p.17). In addition, the chart should be signed by the attending nurse. Furthermore, as per Standard 4 of the NSQHS, ensuring medications are stored appropriately and expired drugs are put away in the appropriate waste chamber is imperative to protect colleagues and preventing medication errors in the workplace (Australian Commission on Safety and Quality in Health Care, 2017). Ensuring that patient’s clinical parameters are within limits is a major consideration. Checking vital signs prior to providing medication is considered significant while administering medications (Berdot et al., 2013,p. 111). Writing up a care plan listing tasks that need to be completed should ensure a systematic approach with prioritization of most important tasks (Graan, Botti, Wood & Redley, 2016, p.169).
Regular IV antibiotic administration facilitates a faster reabsorption and better assimilation inside the body. The pharmacokinetic mechanism involves better drug absorption, distribution and elimination (Barr et al., 2013, p.269). Intravenous antibiotic assistance can be administered either through syringes or catheter and evidences have revealed an enhanced efficacy up to 85% compared to the antibiotics taken orally (Roberts et al., 2015,p.84). Plasma concentrations in the body are fundamentally govern the process of drug binding and elicit effect. It is also based on lipid solubility, binding of plasma proteins, as well as individual factors such as tissue perfusion and vascularity (Glowacki, 2015,p. 40). Regular IV antibiotic administration will facilitate rapid response to the medication in contrast to oral absorption which requires a longer time period to express the effect (Engelbrecht, Wood & Cole-Sinclair, 2013, p. 398). During the process of distribution, antibiotics target infections which are commonly located in the extra vascular space, relying on the process of crossing from the bloodstream into the interstitial space (Rhodes et al., 2017). This is faster when the antibiotic is injected directly into the blood-stream and doesn’t have to go through the stomach and gut first. (Barr et al., 2013, p. 265) emphasized the importance of saving lives by administering antibiotics to patients with suspected sepsis within the first hour. In this case it would be impractical to prescribe oral antibiotics. Due to an increase in extra-vascular space during the inflammatory response to infection, b-lactams a type of hydrophilic agent should be administered immediately (Glowacki, 2015, p35). B- lactams such as cephalosporins have a half-life up to 3 before being excreted via the kidney in their whole form (Rhodes et al., 2017, p. 308). On the other hand, lipophillic antibiotics such as erythromycin, amacrolide, metabolizes in the liver as a result of protein binding (Sorli et al., 2013,p. 382). In terms of effectiveness time between antibiotics, a systematic review by Poole (2014,p. 20) concluded that there is no difference between continuous and intermittent IV antibiotic administration in terms of improving bacterial infections. In contrast however, regular IV therapy can result in inflicting harm to the patient. This can be due to phlebitis, thrombosis, or bacterial infection of the IV site (Rhodes et al., 2017, p. 310). However, these factors do not outweigh the benefits of timely treatment achieved through IV antibiotics.
Australian Commission on Safety and Quality in Health Care (2017). NSQHS Standards (second edition). Retrieved from https://www.safetyandquality.gov.au/wpcontent/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standardssecond-edition.pdf
Australian Nursing and Midwifery Council (2016). ANMF VIC Branch Policy. Retrieved from https://www.anmfvic.asn.au/~/media/files/anmf/vic%20branch%20policies%20and% 20position%20statements/double%20checking%20of%20medication%20prior%20to %20administration.pdf
Australian Sepsis Network (2018) Recognising Sepsis. Retrieved from https://www.australiansepsisnetwork.net.au/healthcare-providers/recognising-sepsis
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