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?
Check a full set of vital signs Auscultate lungs to assess for aspiration
Check IV site to ensure it is secure and not leaking
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?
D-Dimer to assess for the presence of clotting in the system
Coagulation studies (PT, PTT, PT/INR)
CBC to check H/H
CMP to assess kidney and liver function
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.
She is in DIC – her body has been showering microclots because of the sepsis and has now completely used up all of her clotting factors – now she is hemorrhaging
Critical Thinking Check
Bloom's Taxonomy: Analysis
What orders would you anticipate from the provider?
She needs replacement of clotting factors – cryoprecipitate, fresh frozen plasma, and possibly even Factor VII. She may require fluids and a blood transfusion (PRBCs) She may also require a Heparin infusion
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?
We give clotting factors to replace the ones that have been used up/consumed. Fresh Frozen Plasma and Cryoprecipitate both contain large amounts of clotting factors. Heparin is given with the goal of STOPPING the clotting cascade. Once the cascade is stopped, we continue to replace clotting factors and then wean off the heparin. We also want to prevent the formation of new clots.
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.
Invasive procedures should be avoided whenever possible when a patient is in DIC. You should suggest frequent weights or to do a bladder scan to determine if she is retaining urine before inserting the foley catheter.
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.
Unfortunately in DIC, sometimes the process is too severe and we cannot replace blood/factors fast enough. It’s possible that earlier intervention could have helped, or that maybe Massive Transfusion Protocol should have been initiated. Ultimately, there’s no way to know if that would have changed the outcome
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 