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Disseminated Intravascular Coagulation Case Study (60 min)

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Mrs. Terry was admitted to the ICU yesterday for severe acute septic shock. She was started on vasopressors and intubated for airway protection. During your morning assessment, you suction her ET Tube and find specks of blood in the sputum. You also note oozing at her PIV site.

Critical Thinking Check
Bloom's Taxonomy: Application

What further nursing assessments should you perform?

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You notify the provider and Respiratory Therapist (RT). Neither are concerned about the blood specks in the sputum due to a possible traumatic intubation the day before. Two hours later, you and a UAP are turning the patient when you notice a large flank hematoma and petechiae on the patient’s legs, arms, and abdomen. The patient’s left leg feels cool to touch.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What is the significance of the petechiae and flank bruising?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests would you request from the provider?

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You note that Mrs. Terry has even more bleeding from her IV site when you go to draw her blood. Before you can get the results back, the patient begins to vomit blood. You suction her mouth and throat, then the ET Tube and note even more blood secretions from the lungs. After a coughing fit, Mrs. Terry is now oozing blood from her eyes and nose. You immediately call the provider to the bedside and notify your charge nurse of the situation.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What is going on physiologically with Mrs. Terry?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What orders would you anticipate from the provider?

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  • The provider orders to transfuse 2 units of Fresh Frozen Plasma (FFP), 1 unit of Cryoprecipitate, and to initiate a Heparin infusion.
  • Critical Thinking Check
    Bloom's Taxonomy: Analysis

    Explain the rationale for these medications. Why give clotting factors AND Heparin?

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    Over the next 8 hours, you transfuse a total of 6 units of Packed Red Blood Cells (PRBCs), 3 units of FFP, 1 unit of Cryo, and 3 liters of crystalloids. Mrs. Terry’s BP is 92/49, HR 118, Hemoglobin 7.2, Hematocrit 22%, and she is still bleeding from her ET Tube, nose, eyes, IV sites, and now rectally. The provider orders for you to insert a foley catheter to measure I&O.

    Critical Thinking Check
    Bloom's Taxonomy: Analysis

    How should you respond? Why?

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    During the night, Mrs. Terry develops severe acute kidney injury and is requiring 3 vasopressors. The nephrologist determines that she needs dialysis, but it is not possible because at this point it is not safe to place a Vascular Access Device. Despite continuous treatment, blood transfusions, and administration of clotting factors, Mrs. Terry’s heart stops. You and your coworkers perform CPR for more than 20 minutes, while blood is still coming from Mrs. Terry’s mouth, nose, etc. After 6 minutes in Asystole, the provider calls time of death.

    Critical Thinking Check
    Bloom's Taxonomy: Analysis

    Would you have done anything differently? Why?

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