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(
a) Based on D.G. history and the current clinical picture, what
are potential causes for symptoms (GI, Respiratory, GU)?
(b) What information would be useful at this time for diagnosis?
Case Study Cont.
MD orders CBC and coagulation screen. The results are as
follows:
WBC <100 PT 34 sec
ANC 0 PTT 72
Plts 12 Fibrinogen <100
Hct 23 FSP >1000
Hgb 9 D-dimer >500
(
c)What secondary process is possibly occurring based on
above values?
(
d)What interventions are appropriate? What should be the
focus of your assessments?
Case Study Cont.
D.G. Continues to be hypotensive. Lung sounds
remain course, hemoptysis develops and CXR
continues with diffuse consolidation. Urine and
stool remain heme positive. After transfusion,
labs redrawn. Values as follows:
Plts 22 Pt 28
Hct 26 PTT 54
Hgb 10 Fibrin <100
FSP >1000
(
a)What is the results of treatment based on abov
e values?
(b)What interventions should be done?
Case Study cont.
D.G. status continues to deteriorate and
needed to be intubated 2 days after
developing DIC. The sepsis remained
unresolved and he went into acute renal
failure. Family decided not to dialyze due
to the multi-organ involvement. D.G.
expired 2 days later from the gram neg
sepsis and secondary DIC.
Answers for Case Study
(a)Risk for infection, renal insufficiency,
neutropenia, bleeding based on lab
values. WBC low along with the ANC
makes patient more susceptible to
infection. The BUN and creatinine are
elevated leading to possible renal
problems
Answers for Case Study
(b) Possible septic shock as a result of an
underlying infection. Neutropenic patients
are at high risk for development of
infections.
(c) Patient will need blood cultures and labs
drawn, a fluid challenge is needed to help
with low BP’s. Will need to be started on
antibiotics. Patient will need to be
monitored closely, VS, I&O’s …
Answers for Case Study
(a) D.G.’s labs cont to show anemia,
neutropenia, renal insuffiency/failure.
BUN and creatinine have increased and
the H&H has falling since previous draw.
The ANC conts to drop.
(b) Fluids, PRBC transfusion, monitoring of
urine output and VS are needed at this
time. The transfusion and fluids will help
with hypotension and anemia.
Answers for Case Study
(a) Pt possibly developing hypoxemia as a
result of the infection process,
hypotension.
(b) Need to monitor O2 sats and apply
oxygen. Need to get orders for CXR and
cont to monitor Vital signs closely.
Answers for Case Study
(c) Patient maybe developing pneumonia
and is at an increased risk for ARDS
(acute respiratory distress syndrome).
The moist cough with rapid resp. rate is
good indication of pulmonary
involvement.
The patient also has increased risk of
developing DIC based on the clinical
presentation and risk factors presented.
Answers for Case Study
(a) The clinical presentation leads to the
diagnosis of DIC (effects every system of
the body); Lungs- hypoxemia,
hemorrhage, tachypnea Cardiac-
acidosis, tachycardia GI- cramping,
abdominal pain Renal- hematuria
Integument- bruising, petechiae Mental
status changes- confusion
Answer for Case Study
(b) A DIC panel results would be helpful at
this time. Lab abnormalities along with
clinical presentation is used to confirm a
diagnosis of DIC. If abnormal results are
obtained for PT, PTT, platelets, and
fibrinogen, then the D-dimer and FDPs
levels are used to confirm DIC...FDPs
abnormal in 75% and D-dimer in 95%.
(Otto, 2001)
Answers for Case Study
(a) Based on the lab values, DIC is confirmed for
the patient. The Platelet count is decreased,
the fibrinogen level is decreased, PT and PTT
levels increased and prolonged, FDPs level is
increased and the D-dimer is increased
(usually together, levels are 100% specificity
and sensitive). If a factor assay was done one
would expect the levels to show a decrease in
factors VI, VIII, and IX
(Otto, 2001)
Answers for Case Study
(b) The immediate goal for the overall
management of DIC is the treat the underlying
disorder and to stop the patient from actively
bleeding and clotting with the need to give
transfusions and anticoagulation therapy if
needed.* Focus of assessments is to monitor
for more bleeding and changes.
*Heparin therapy has met with controversy for the
treatment of DIC
(Porth, 2004) & (Otto, 2001)
Answers for Case Study
(a) Based on the lab values, DG shows
slight improvement. The PT and PTT
numbers are better, platelet level has
increased.
(b) The patient will cont to need to be
monitored very closely. Will need to cont
with treatment, monitor lab values
frequently. Patient remains critically ill.
References
Otto, Shirley E. (2001). Oncology
Nursing. Mosby: St. Louis.
Porth, Carol M. (2004). Essentials of
Pathophysiology: Concepts of Altered
Health States. Lippncott Williams &
Wilkins: Philadelphia.
Web Sites:
Pat Bowne, faculty Alverno College Milwaukee Wis.
Glossary
Complement-a heat-labile cascade system of at least 20
glycoproteins in normal serum that interacts to provide
manu of the effector functions of humoral immunity and
inflammation, including vasodilation and increases of
vascular permeability, facilitation of phagocyte activity
and lysis of certain foreign cells.
F’s (factors) of Coagulation:factors essential to normal
blood-clotting, whose absence, diminution, or excess
may lead to abnormality of clotting mechanisms. There
are 12 Factors-designated by Roman Numerals.
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