Help me please
Marie Case Study 1
Scenario: Marie is a 27 year old female who is homeless. She arrives at the emergency
department with complaints pain in her left foot. After an assessment you discover that she has
an open wound on the bottom of her left foot that is red, swollen, and draining green fluid.
Cellulitis is present up the leg to the knee. She states she has no chronic medical illnesses and
doesn’t take any medication. She is alert and oriented to person, place and time. Her vitals are
BP: 100/78 (her normal is 120/80), Heart Rate 100, Temperature 100.5, Pulse Ox 98%,
respiratory rate is 22.
What condition are you suspecting?
Based on the symptoms presented—pain, redness, swelling, drainage of green fluid from the
foot, and cellulitis extending up to the knee—Marie is likely suffering from a severe bacterial
infection, possibly progressing to sepsis given the systemic symptoms (Salomão et al., 2019).
Does she have at least 2 criteria for Systemic Inflammatory Response Syndrome? If so, list
the criteria.
By the SIRS definition, Marie experiences the minimum grade of symptoms including a
temperature higher than the normal threshold and the heart rate that is greater than 90 bpm. For
instance, temperature is 100.5°F and the rate of the heart is 100 beats per minute. These
symptoms that point to her body fighting a major battle to recover from the infection and
possibly leading to septic shock (Otto, 2020).
What are your next steps?
Immediate actions should include (Otto, 2020):
• Continued monitoring of vital signs.
• Administering IV fluids and antibiotics.
• Preparing for possible escalation of care depending on the patient’s response.
What medication do you expect to be given, if any?
Antibiotics remain the basis for the treatment of bacteriological infections that help to
avoid further progress to sepsis. This would mean recommending suitable pain killers or
antipyretic drugs like aspirin for fever (Gyawali et al., 2019).
What labs do you expect the doctor to order?
The doctor is likely to order a complete blood count (CBC), blood cultures, lactate levels,
and other tests to assess the extent of the infection and organ function (Otto, 2020).
Is she improving?
Marie is not showing signs of improvement; her vital signs indicate worsening conditions
such as increased heart rate, respiratory rate, and fever. The chills and paleness could
suggest systemic infection progression (Salomão et al., 2019).
What do you expect the licensed practitioner to order?
The practitioner may order adjustments in antibiotic therapy based on culture results,
increased fluid administration, and potentially vasopressors if hypotension persists
(Gyawali et al., 2019).
If she was not improving, what would she be at risk for?
If Marie does not improve, she could be at risk for septic shock, organ failure, and
increased mortality (Gyawali et al., 2019).
What makes a person high risk for infection?
Factors include compromised immune system, chronic health conditions, wounds or injuries,
homelessness (exposure to unsanitary conditions), and lack of medical care (Otto, 2020).
Define sepsis.
Sepsis is an acute endogenous disease, caused by the body’s overall response to an infection
involving the development of damage to tissues, organs failure, and death (Gyawali et al., 2019).
In your own words, explain septic shock?
Septicemia (sepsis shock) is a severe state of an ill patient and blood pressure decrease occurs
secondary to septicemia by causing impaired metabolism in all body cells with septic
manifestations and multi-organ failure accompanied by extremely poor cardiovascular
metabolism and high mortality rate.
In your own words, explain the pathophysiology of Septic shock.
Septic shock results from the massive reaction of the immune system to an infection with
impaired normal organ and tissue function. The septic shock physiology involves different parts:
vessel dilatations, blood clot formations, and organ failures.
Give 2 examples of medications that can be used to treat Sepsis.
• Antibiotics: Essential for treating the underlying infection (Otto, 2020).
• Vasopressors: Used to stabilize blood pressure if fluid resuscitation is not sufficient
(Gyawali et al., 2019).
References
Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition,
pathophysiology, and management. SAGE open medicine, 7, 2050312119835043.
Otto, C. M. (2020). Sepsis. In The veterinary ICU book (pp. 695-709). CRC Press.
Salomão, R., Ferreira, B. L., Salomão, M. C., Santos, S. S., Azevedo, L. C. P., & Brunialti, M.
K. C. (2019). Sepsis: evolving concepts and challenges. Brazilian Journal of Medical and
Biological Research, 52, e8595.
Disseminated Intravascular Coagulation Case Study 2
Jerry is a 24 year old in the ICU that was hit by a car while walking 7 days ago. This
accident resulted He began to develop sepsis. Day 8 you notice petechiae on his torso and
blood oozing from his past IV insertion sites. His suture lines from his hip surgery are
oozing blood as well. Based on your assessment, you suspect disseminated intravascular
coagulation (DIC).
Explain why you suspected that Jerry developed DIC (scenario data and textbook
support)?
Elevating the probability of DIC in Jerry’s case is based on pivotal signs noted in the case. First
of all, the occurrence of petechiae on his torso and bleeding from past venous cannulation sites
and suture lines signify the abnormal tendency of bleeding, characteristic feature for DIC (Lehne
& Rosenthal, 2019). Besides that, Jerry’s previous trauma experience from being hit by a car
could have initiated a domino effect that led to DIC. Trauma is the main cause of DIC, where
disintegration of cells and release of procoagulant compounds in blood overload the body system
by shutting off the vital anticoagulants mechanisms. This results in microvascular thrombosis
and depletion of clotting factors and platelets with the sequel of bleeding (Keohane et al., 2019).
Define Disseminated Intravascular Coagulation.
Disseminated intravascular coagulation (DIC) is characterized by systemic activation of
coagulation cascade leading to thrombi and hemorrhages. Generally, it is the state where the
body’s clotting response becomes hyperactive, and therefore, multiple small clots form in the
blood vessels (Keohane et al., 2019). These clots are destructive to organs and tissues and
simultaneously denies the body more and more clotting factors and platelets, causing a bleeding
tendency.
What labs do you expect to be ordered?
Jerry’s diagnosis of DIC could probably be confirmed by through some laboratory tests in order
determine its severity. Per Smith (2021), these may include:
• Complete Blood Count (CBC) with platelet count
• Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
• Fibrinogen levels
• D-dimer assay
• Peripheral blood smear
With each lab value, indicate if that value would be abnormally high or low for a pt.
with DIC and explain.
In DIC, testing laboratory often shows abnormalities which show elements of both
thrombosis and hemorrhage. According to Smith (2021), these are specifically:
• • Platelet count: Initially high platelet counts are observed due to the platelet activation
and consumption, but as DIC progresses, thrombocytopenia (low platelet count) develops
due to continued platelet destruction.
• PT and PTT: These values can be maintained over a longer period of time with additional
clotting factors.
• Fibrinogen: Initially high due to acute phase response, but the tendency reverses as DIC
progresses with fibrinogen level falls due to incessant consumption in clot formation.
• D-dimer: Elevation resulting from clot degradation mediated via fibrinolysis. What is the
pathophysiology causing the change in lab values?
The pathogenesis of DIC is based on the activation of the coagulation cascade via different
triggers that could be related to trauma, sepsis, or obstetrical problems. These triggers
consequently initiate the process that produces thrombin, which subsequently converts
fibrinogen into fibrin and causes the development of microthrombi in vasculature (Lehne &
Rosenthal, 2019). Concurrently with the contribution of coagulation factors and platelets in
microthrombi formation, the coagulopathy is disrupted and the patient becomes more prone to
bleeding.
What are patients with DIC at risk for due to the abnormally high consumption of clotting
factors and platelets and why?
Patients with DIC often develop complications that may progress to organ dysfunction or multi-
organ failure ultimately due to the formation of microvascular thrombosis leading to eventual
tissue damage. Moreover, the plasma elements important in clotting like clotting factors and
platelets can be reduced leading to severe hemorrhage and bleeding from several sites that may
be fatal when if treated on time (Keohane et al., 2019).
How is DIC managed?
The management of DIC involves addressing the root cause along with providing supportive care
so as to manage the bleeding and thrombotic complications. According to Lehne & Rosenthal
(2019), treatment may include:
• Management of the cause like sepsis or traumatic injuries is essential.
• Transferring blood products like platelets, fresh-frozen plasma, and cryoprecipitate to
correct clotting abnormalities.
• Anticoagulant therapy for selected patients to hinder future thrombin generation.
• Measures including mechanical ventilation and the management of organ failure with
hemodynamic support will also be employed.
• Regularly checking laboratory values and clinical status to guide management decision
making.
References
Keohane, E. M., Otto, C. N., & Walenga, J. M. (2019). Rodak’s Hematology-E-Book: Rodak’s
Hematology-E-Book. Elsevier Health Sciences.
Lehne, R. A., & Rosenthal, L. (2019). Pharmacology for Nursing Care-E-Book. Elsevier Health
Sciences.
Smith, L. (2021, April). Disseminated intravascular coagulation. In Seminars in oncology
nursing (Vol. 37, No. 2, p. 151135). WB Saunders.
