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Case Study

Berniece Jones is a 87 year old female that was brought into the ER by EMS with a productive cough, shallow respirations and malaise. Her vital signs were:

• Temp: 101.8
• Heart Rate: 124
• Respiratory Rate: 27
• Oxygen Saturation: 89%
• Blood pressure: 87/56
• MAP: 63

On assessment, the patient did not complain of any pain. She was alert and oriented to person and place with a pleasant demeanor. She denied a headache and denied any dizziness. Her pupils reacted briskly to light, they were equal in size and round. A bounding pulse was noted peripherally. Capillary refill was less than three seconds. The patient had normal heart sounds but tachycardic. Her breathing was shallow and rapid with bilateral crackles noted. She reported nausea but could not determine if she had vomited recently. Her skin was warm and flushed. Tenting was noted. She was placed on 10 liters of oxygen via a rebreather face mask. A 20 gauge IV was initiated in her right antecubital and blood cultures and labs were drawn. A chest x-ray was ordered. At this point a caregiver and the patient’s daughter from her assisted living facility, Rivervalley, arrived. The caregiver explained that the patient has had a productive cough for the past 6 days. They called ems when they noted she became more confused, had trouble breathing this morning and had stopped taking her medications for the past couple of days. Her medical history included rheumatoid arthritis (RA) and hypertension. Her home medications are Methotrexate and Celecoxib for her RA, and Aspirin and Atenolol for her hypertension. She has no known allergies.

The chest x-ray showed bilateral diffused consolidations.

Labs:

She was diagnosed with pneumonia and sepsis. Suspecting septic shock, the provider ordered a liter bolus of normal saline and IV ceftriaxone. An indwelling foley catheter was ordered for strict I&O monitoring. The nurse started another 20 gauge IV in her left antecubital and started the fluids. Vitals were:

• Temp: 101.8
• Heart Rate: 122
• Respiratory Rate: 25
• Oxygen Saturation: 92%
• Blood pressure: 84/54
• MAP: 59

Soon after, the nurse noted blood around patient’s IV site. Bleeding could also be seen around her gums and nose. The patient was oriented to self. She did not respond well to commands and her pupils reacted sluggishly to light. She complained of a “heartburn” sensation. Her capillary refill was greater than 3 seconds. Her lips, fingertips, toes, ears and nose were cyanotic. The patient grimaced on inspiration and her left lung lobes were diminished in sound. Her abdomen was distended and rigid. Her vitals and repeat labs were:

• Temp: 100.2
• Heart Rate: 62
• Respiratory Rate: 6
• Oxygen Saturation: 82%
• Blood pressure: 84/52

New labs were drawn:

The patient was then diagnosed with DIC, intubated and transferred to the ICU for further care and monitoring. Once in the ICU, one of the doctor’s orders included fresh frozen plasma and PRBCs. The daughter became visibly upset stating that she and her mother are both Jehovah Witnesses. The ethics board, case management, and the physician were then notified of the case. Treatment options were then discussed with daughter and family.

Open ended questions:

1.) What other orders can the nurse expect from the provider?

Low molecular-weight heparin. Cryoprecipitate along with fresh-frozen plasma to replace coagulation factors. Continuation of norepinephrine for vasopressor support. Fibrinolytic inhibitors along with heparin. Oxygen, fluid replacement, correcting electrolyte imbalance. Continuation of antibiotic therapy and more specific antibiotics when results from blood cultures are obtained (Hinkle & Cheever, 2015).

2.) What are the priority nursing interventions for this patient?

Proper oxygenation, hemodynamic stability, monitoring for excessive bleeding or organ failure from microclotting (Hinkle & Cheever, 2015).

3.) How would you approach this case in relation to the patient’s religious practice and need for intervention?

Open discussion with class

References

Hinkle, J. L., & Cheever, K. H. (2014). Textbook of medical-surgical nursing. (13th ed.).

Philadelphia, PA: Lippincott Williams & Wilkins.