JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING AND HEALTH SCIENCES

S. Y. 2021-2022

CLO2 (P): Case Study - Care of Clients with alterations in Oxygenation-Transport

In Partial Fulfillment of the Requirement in

CARE OF CLIENTS W/ PROB IN OXYGENATION, FLUID & ELECTROLYTES, II&IR, CA, A&C

Submitted by:

Rhyann Jervy Advincula Rochelle May Flores

Maria Lyn Arandia Marylle Diane Gadiano

Louise Carol Arlos Ashley Angel Mabait

Syrene Lormay Canelas Farrah Sophia Queen Mejiano

Mark Geoffrey Dela Cruz Jiza Jane Saraspe

Submitted to:

Prof. Jierico Paul C. Batario RN, MSN-AHN, FPSQUA

EPIDEMIOLOGY AND ETIOLOGY OF THE CASE

Multiple organ dysfunction syndrome, or MODS, is caused by disseminated intravascular coagulation (DIC), which is characterized as a widespread hypercoagulable state

that can result in both microvascular and macrovascular clotting and impaired blood flow. Hemorrhage can occur as a result of this process consuming clotting factors and platelets

in a positive feedback loop, which may be the presenting sign of a patient with DIC. Patients with underlying life-threatening conditions such as severe sepsis, hematologic

malignancies, severe trauma, or placental abruption are more likely to develop disseminated intravascular coagulation as an immediate consequence. Determining the long-term

effects of DIC and its overall mortality rate is difficult since individuals with this syndrome often have other diagnoses that cause many of the same signs and symptoms as DIC,

especially if they also have acute or chronic liver failure. While simultaneous disease conditions can mask a patient's prognosis, fatality rates in septic patients or those with severe

injuries who also have DIC have been observed to double.(Costello et.al., 2021)

Because DIC is a consequence of other medical illnesses, higher acuity settings have a higher prevalence of DIC than lower acuity settings. A severe or life-threatening

diagnosis is almost always connected with the condition. According to a research conducted in Japan in 1996, DIC complicated around 1.0 percent of admissions to university

hospitals. DIC was found in 78 percent of cases during remission induction in a 1992 research, and it complicated 12 percent of cases with acute lymphoblastic leukemia before

starting chemotherapy. According to a 1993 study, HELLP syndrome was linked to DIC in about one out of every five cases. (Okajima et.al., 2000)
SIGNIFICANCE OF THE STUDY

The study will be beneficial to the following roles:

Patient. To encourage engagement in improving the health outcomes and reduce the cost extending the reach of treatment and diagnosis of the patient. To prevent adverse health

care events and illnesses to the patient's safety and maintain the overall health and well-being.

Immediate family caregiver to the patient. To provide an effective approach in supporting and providing care related to the safety in the demands of the patient at high risk for

injury and illnesses/disease, also to the need for nurses to proactively approach family caregivers as clients who need their support and holistic care.

Society. To improve the quality of life of the people in the community. This study will serve as a basis for knowledge and learning that will promote health among the people,

and prevent illness or adverse effects through treatment ideas. To learn who is at risk, what is the cause and what is the nature of the disease and its manifestations.

Academe. To focus more on establishing and conducting more related studies that may tackle other aspects of the disease. To be able to build a stronger foundation through

evidence-based practices that may be used in treatment of DIC.

Professionals. Specifically, for health professionals, to become well informed about DIC. To provide new efficient health care management of the disease through studies and

research. To be able to render quality and patient-centered care effectively. Moreover, to reduce morbidity and mortality rates among patients with DIC.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data: Risk for Infection related to Short Term: Independent: Independent: Short Term:

● Patient noted tissue destruction After 8hrs of nursing - Maintain sterile To reduce the number of Goal Met.

prolonged bleeding secondary to Disseminated intervention, the client will technique for all potentially infectious After 8 hrs of nursing

at venipuncture site Intravascular Coagulation be able to understand her invasive procedures microorganisms as well as intervention, the client was

and oliguria as evidenced by underlying condition as such as IV and to reduce the risks of able to verbalize:

foul-smelling vaginal evidence by verbalizing: Urinary Catheter acquiring infection before a.) the factors causing her

discharge and ↑WBC a.) the factors causing her Insertion. and during invasive infection (e.g. illegal

Objective Data: infection (e.g. illegal procedures. abortion, retained placental

● Foul smelling abortion, retained placental tissue)

vaginal discharge tissue) b.) the significance of

associated with b.) the significance of following her prescribed

ecchymosis on the following her prescribed regimen.

left upper arm regimen c.) self-care management in

Laboratory Findings: Rationale: c.) self-care managements accordance to her current

The elevated number of in accordance to her - Maintain adequate Replacing fluid losses can health status (e.g. keep the

● 16,000 cu mm WBC and foul smelling current health status hydration by help the skin and mucous vagina clean using a gentle,

WBC vaginal discharge can increasing oral membrane cells to fight off mild soap and warm water

● 300,000 cu mm possibly indicate existing Long Term: intake of fluid or IV or prevent bacteria from on the outside, avoid using

Platelet infection. Existing After 7 days of nursing isotonic solution. entering the body. scented soap)

● Prolonged PT infection can cause intervention, the client will

● Prolonged PTT accumulation of blood be able to lessen the Risk - Educate the client This will increase the

● Depressed clots protein to the infected of Infection secondary to about the cause of patient adherence to

Fibrinogen Level site, this blood protein can Disseminated Intravascular her infection (the medication and treatment

● Positive Protamine become abnormal and can Coagulation. sudden rise of her regimens. Long Term:

Sulfate cause DIC. a. decrease WBC for WBC count and her Goal met.

● Increase BUN and atleast 2,000 to foul smelling After 7 days of nursing

Creatinine 4,000 cu mm vaginal discharge). intervention, the client was

b. returns to normal able to lessen her risk of

vaginal flora infection as evidenced by:

- Encourage the To avoid irritation and a.) decreased WBC count

patient to use mild allergic reactions. Using (11,000 cu mm WBC)

soap and wash it mild soap and warm water b.) returned to normal

gently with warm will not remove the natural vaginal flora

water. fluid that keeps the vaginal

clean.

- Instruct the patient

To prevent bacteria from
that after going to
getting into vagina and
the bathroom,
causing an infection.
always wipe from

front to back.
Dependent: Dependent:

- Administer and To lessen the risk of

monitor Antibiotic infection.

medications such as

Cleocin

(Clindamycin).

- Assist in Dilation & To remove possible

Curettage as retained placental or

prescribed. abortion tissue.

- Assist in medical To assess or determine

procedures such as possible retained products

transvaginal of conception.

ultrasound or other

confirmatory tests.
Collaborative: Collaborative:

Obtain appropriate vaginal To determine the type of

discharge specimens for bacteria existing.

observation and culture and

testing.
 DRUG STUDY

DRUG INFORMATION AND DRUG ACTION DRUG EFFECTS DRUG NURSING CONSIDERATIONS
DRUG ADMINISTRATION

Generic name: Clindamycin(RX) Indication: Side effects: ● Monitor signs of pseudomembranous

● Treatment of serious infections ● Any change in bowel movements; colitis, including diarrhea, abdominal
caused by susceptible anaerobic ● Severe stomach pain, diarrhea that is pain, fever, pus or mucus in stools,
bacteria, as well as susceptible watery or bloody; and other severe or prolonged GI
Brand name: Cleocin staphylococci, streptococci, and ● Little or no urination; or a metallic taste problems (nausea, vomiting,
pneumococci. in your mouth heartburn). Notify physicians or
● Does not penetrate the blood/brain ● Nausea, vomiting, mild skin rash; or nursing staff immediately of these
barrier in therapeutically effective ● Vaginal itching or discharge signs.
quantities. ● Assess dizziness or vertigo that
Classification: Antibiotics
might affect gait, balance, and other
functional activities. Report balance
Adverse effect: problems and functional limitations to
Mode of action: ● Hypersensitivity Reactions - the physician and nursing staff, and
● Clindamycin works primarily by Maculopapular rash and urticaria have caution the patient and
Sub-Classification: Lincosamide binding to the 50s ribosomal subunit been observed during drug therapy. family/caregivers to guard against
of bacteria. This agent disrupts Generalized mild to moderate falls and trauma.
protein synthesis by interfering with morbilliform-like skin rashes are the ● Assess heart rate, ECG, and heart
the transpeptidation reaction, which most frequently reported of all adverse
sounds, especially during exercise.
thereby inhibits early chain reactions.
Report any rhythm disturbances or
Dosage: 600 to 1,200 g per day divide every 6 elongation.
symptoms of increased arrhythmias,
hours ● Gastrointestinal -
including palpitations, chest
Antibiotic-associated
 colitis,pseudomembranous colitis, discomfort, shortness of breath,
Route: Intravenous Infusion Pharmacokinetics: abdominal pain, nausea, and vomiting. fainting, and fatigue/weakness.
● Absorption The onset of pseudomembranous ● Monitor injection site for pain,
○ When the equivalent of colitis symptoms may occur during or swelling, and irritation. Report
300mg of clindamycin is after antibacterial treatment. An prolonged or excessive injection site
Frequency: Continuous injected intramuscularly, a unpleasant or metallic taste has been reactions to the physician.
mean peak plasma reported after intravenous ● Assess blood pressure periodically,
concentration of 6 administration of the higher doses of and compare to normal values.
microgram/ml is achieved clindamycin phosphate. Report low blood pressure
Preparations: within three hours; 600mg (hypotension), especially if the
● A single 1 hour IV infusion greater than gives a peak concentration ● Local Reactions - Injection site patient experiences dizziness,
1,200 mg is not recommended of 9 microgram/ml. In irritation, pain, induration and sterile fatigue, or other symptoms.
● Intravenous doses should be diluted children, peak concentration abscess have been reported after
and administered as an infusion over may be reached within one intramuscular injection and
10 to 60 minutes, at a rate not hour. When the same doses thrombophlebitis after intravenous
exceeding 30 mg/min. are infused intravenously, infusion. Reactions can be minimized
● Clindamycin for intravenous use must peak concentrations of 7 or avoided by giving deep
be diluted prior to administration and 10 micrograms per ml intramuscular injections and avoiding
● The concentration of clindamycin in respectively are achieved by prolonged use of indwelling
diluent for IV infusion should not the end of infusion. intravenous catheters.
exceed 18 mg/mL.
● May give continuous IV infusion
instead of intermittent after the first
dose has been given by rapid IV
infusion.
 ● Distribution ● Musculoskeletal - Polyarthritis cases
Special Considerations: ○ Clindamycin is widely have been reported.
● Clindamycin should be given to official distributed in body fluids and
guidance on the appropriate use of tissues to the bone . It
antibacterial agents. diffuses across the placenta
into the foetal circulation and Contraindication:
appears in breast milk. High ● Clindamycin is contraindicated in
concentrations occur in bile. patients with a history of
It accumulates in leukocytes pseudomembranous colitis or
and macrophages. Over ulcerative colitis. Hypersensitivity to
90% of clindamycin in the clindamycin, lincomycin, or formulation
circulation is bound to components.
plasma proteins.
○ The half-life is 2 to 3 hours, Food and Drug interaction:
although this may be ● It's recommended that antibiotics are
prolonged in pre-term not taken with dairy products such as
neonates and patients with cheese, milk, butter, and yogurt should
severe renal impairment. not be consumed until 3 hours after a
dose of antibiotics is taken. Likewise,
● Elimination juices or supplements containing
○ About 10% of the drug is calcium may also reduce effectiveness.
excreted in the urine as ● It is recommended to take with a full
active drug or metabolites glass of water. Clindamycin may cause
and about 4% in the faeces; esophageal irritation if the dosage form
the remainder is excreted as becomes lodged.
 inactive metabolites. ● Take with or without food. Food does
Excretion is slow and takes not appreciably alter the absorption of
place over several days. It is clindamycin.
not effectively removed from ● Alcohol: Drinking alcohol cannot affect
the blood by dialysis. clindamycin but when you feel unwell
with your infection, or if you find
clindamycin gives you an upset
stomach, then drinking alcohol could
make this worse.
Pharmacodynamics: ● Drug:
● Clindamycin exerts its bacteriostatic ○ Abiraterone and Acalabrutinib
effect via inhibition of microbial cab decreased the metabolism
protein synthesis. Clindamycin has a of Clindamycin.
relatively short Tmax and half-life ○ Erythromycin: Clindamycin and
necessitating administration every another antibiotic called
six hours to ensure adequate erythromycin can compete
antibiotic concentrations. against each other. This
competition may decrease the
effectiveness of antibiotic
medications. Therefore,
Therapeutic effect: patients should not take them
● Bactericidal or bacteriostatic, together.
depending on susceptibility and
concentration.
Generic Name: Heparin(Rx) Indication Side Effects ● Monitor symptoms of deep
● Prophylaxis and treatment of venous ● Easy bleeding and bruising; veinthrombosis (DVT) (pain,
thromboembolism and pulmonary ● Pain, redness, warmth, irritation, or swelling, warmth, redness) to
embolism; skin changes where the medicine was determine if drug therapy is effective
● Atrial fibrillation with embolization; injected; in preventing or reducing venous
Brand Name: Lovenox
● Treatment of acute and chronic ● Itching of your feet; or thrombosis. Request or administer

consumptive coagulopathies objective tests (Doppler ultrasound)

● Bluish-colored skin.
(disseminated intravascular if symptoms increase.
coagulation); ● In patients with DVT, watch for signs

Classification: Glycosaminoglycan ● Prevention of clotting in arterial and of pulmonary embolism, such as

cardiac surgery; Adverse Effects: shortness of breath, chest pain,

● Hemorrhage - Hemorrhage is the chief cough, and bloody sputum. Notify
● Prophylaxis and treatment of
complication that may result from physician or nursing staff
peripheral arterial embolism;
Sub-Classification: Anticoagulants heparin therapy. Gastrointestinal or immediately if these signs occur.
● Anticoagulant use in blood urinary tract bleeding during
● Assess for signs of bleeding and
transfusions, extracorporeal anticoagulant therapy may indicate the
hemorrhage, including bleeding
circulation, and dialysis procedures. presence of an underlying occult
gums, nosebleeds, unusual bruising,
lesion. Bleeding can occur at any site
black/tarry stools, hematuria, and fall
but certain specific hemorrhagic
in hematocrit or blood pressure.
Dosage: 20,000 to 40,000 units per 24 hour complications may be difficult to detect:
Mode of Action: Notify physician or nursing staff
○ Adrenal hemorrhage, with
● Heparin binds to the enzyme immediately if heparin causes
resultant acute adrenal
inhibitor antithrombin III (AT), excessive anticoagulation.
insufficiency, has occurred with
Route: Intravenous Injection causing a conformational change heparin therapy, including fatal ● Monitor signs of allergic reactions
that results in its activation through cases. and anaphylaxis, including
an increase in the flexibility of its pulmonary symptoms (tightness in
○ Ovarian (corpus luteum)
reactive site loop. The activated AT the throat and chest, wheezing,
hemorrhage developed in a
then inactivates thrombin, factor Xa
number of women of cough, dyspnea) or skin reactions
Frequency: Continuous and other proteases.
reproductive age receiving (rash, pruritus, urticaria). Notify
short- or long-term physician or nursing staff
Pharmacokinetics: anticoagulant therapy. immediately if these reactions occur.

● Absorption ○ Retroperitoneal hemorrhage. ● Be alert for acute arterial or venous

Preparations: ○ Heparin is not absorbed thrombosis caused by

● HIT and HITT, including delayed onset
through the gastrointestinal heparin-induced thrombocytopenia
cases [see WARNINGS AND
● Recommended infusion concentration tract and therefore (HIT). In certain patients, heparin
PRECAUTIONS].
for most patients is 25,000 units in 500 administered via parenteral initiates an immune reaction where
mL D5W (50 units/mL premixed route. Peak plasma ● Hypersensitivity - Generalized
antibodies attack circulating
infusion solution) concentration and the onset hypersensitivity reactions have been
platelets. Although most cases of
● IV injection may be given undiluted or of action are achieved reported with chills, fever, and urticaria
HIT are minor and asymptomatic,
diluted in 50-100 mL NS or D5W immediately after as the most usual manifestations, and
● Infusion: Dilute in NS, D5W, or other asthma, rhinitis, lacrimation, headache, some patients may experience life-
intravenous administration.
compatible fluid nausea and vomiting, and or limb-threatening platelet clots,
● Distribution
● Continuous IV therapy is preferred ○ Heparin is highly bound to anaphylactoid reactions, including resulting in myocardial infarction,
because intermittent IV therapy antithrombin, fibrinogens, shock, occurring more rarely. Itching ischemic stroke, acute leg ischemia,
produces a higher incidence of globulins, serum proteases and burning, especially on the plantar or venous thromboembolism. HIT
bleeding abnormalities and lipoproteins. The side of the feet, may occur [see can occur during and up to several
● Invert IV bag at least 6 times to ensure volume of distribution is 0.07 WARNINGS AND PRECAUTIONS]. weeks after heparin therapy. Any
mixing and prevent pooling of L/kg.
● Elevations of serum signs of increased clotting should be
 medication ● Elimination aminotransferases - Significant reported immediately.
● Use constant-rate IV infusion pump ○ Metabolism elevations of aspartate ● Watch for unusual weakness and
■ Heparin does not aminotransferase (AST) and alanine fatigue that might be due to anemia.
undergo enzymatic aminotransferase (ALT) levels have Report these signs to the physician
degradation. occurred in patients who have received
or nursing staff.
Special Considerations:
○ Excretion heparin.
● Heparin requires close monitoring ● Monitor and report signs of
■ Heparin is mainly
because of its narrow therapeutic ● Others - Osteoporosis following drug-induced hepatitis, including
cleared from the
index, increased risk for bleeding, and long-term administration of high-doses anorexia, abdominal pain, severe
circulation by liver
potential for heparin-induced of heparin, cutaneous necrosis after
and nausea and vomiting, yellow skin or
thrombocytopenia (HIT). Monitoring systemic administration, suppression
reticuloendothelial eyes, skin rashes, flu like symptoms,
includes thorough head-to-toe patient of aldosterone synthesis, delayed
cells mediated and muscle/joint pain.
assessments for potential side effects, transient alopecia, priapism, and
uptake into ● Assess injection site for pain,
and laboratory monitoring. rebound hyperlipemia on
extravascular swelling, and irritation. Report
discontinuation of heparin sodium have
space. Heparin prolonged or excessive injection-site
also been reported.
undergoes biphasic reactions to the physician or nursing
clearance, a) rapid
staff.
saturable clearance
(zero order process
Contraindication:
due to binding to
proteins, endothelial The use of Heparin Sodium in 0.45% Sodium
cells and Chloride Injection or Heparin Sodium in 5%
macrophage) and b) Dextrose Injection is contraindicated in patients
slower first order with the following conditions:
elimination. The
plasma half-life is
 dose-dependent
and it ranges from
0.5 to 2 h. ● History of Heparin-Induced
Thrombocytopenia (HIT) and
Heparin-Induced Thrombocytopenia
and Thrombosis (HITT)

● Known hypersensitivity to heparin or

Pharmacodynamics: pork products (e.g., anaphylactoid
● Bleeding time is usually unaffected reactions)
by heparin. Various times (activated
● In whom suitable blood coagulation
clotting time, activated partial
tests e.g., the whole blood clotting
thromboplastin time, prothrombin
time, partial thromboplastin time, etc., -
time, whole blood clotting time) are
cannot be performed at appropriate
prolonged by full therapeutic doses
intervals (this contraindication refers to
of heparin; in most cases it is not
full-dose heparin; there is usually no
measurably affected by low doses of
need to monitor coagulation
heparin.
parameters in patients receiving
low-dose heparin)

Therapeutic Effect: ● An uncontrolled bleeding state, except

● Prevents thrombus formation and when this is due to disseminated

existing thrombi. intravascular coagulation.

Food and Drug Interaction
● Vitamin K rich foods: Green leafy
vegetables like broccoli, cabbage,
coriander, collard greens, spinach, kale
black licorice, turnip greens, Brussel
sprouts, and avocados which are rich
in vitamin K decrease the ability of
heparin to prevent blood clotting.
Intake of soy food may affect heparin
activity
● Tobacco products: Smoking may
decrease the effectiveness of heparin .
Usage of tobacco products while taking
heparin will increase the risk of blood
clots.
● Herbs: do not take garlic, ginger,
ginseng, ginkgo, cannabis, saw
palmetto, green tea, papaya, mango,
or onion with heparin as the
combination could alter the risk of
bleeding with heparin

● Drugs: medications that increase the

risk of bleeding such as aspirin,
clopidogrel, warfarin, other
anticoagulants, and nonsteroidal
anti-inflammatory drugs (NSAIDs) such
as ibuprofen, naproxen, diclofenac,
and others, because these add to the
effects of heparin and further increase
the risk of bleeding that is associated
with heparin.
 STUDY CONCLUSIONS & RECOMMENDATION

CONCLUSIONS

Disseminated Intravascular Coagulation can be caused by underlying conditions such as infection. We concluded that Mrs. Sanchez may possibly have an existing

infection or retained placental tissue that didn’t addressed because of illegal abortion this resulted to elevated WBC and foul smell vaginal discharge, with this the lab result also

resulted that the patient is positive in protamine sulfate this may contribute to the main problem. In this case the nursing intervention should focus on the risk of infection and the

high possibility of bleeding.

RECOMMENDATIONS

Here are some tips and recommendations for preventing vaginal infection that can lead to abnormal discharge:

● To keep the vagina clean we recommend to wash it with gentle, mild soap and warm water on the outside. There is no need to put soap directly in the vagina.

● Avoid using scented soaps and feminine sprays and bubble baths. And after going to the bathroom, always wipe from front to back to prevent bacteria from getting

into the vagina and causing an infection.

● Do not douche. Because it can lead to many problems including problems getting pregnant.

● We recommend wearing cotton underpants during the day. Cotton allows genital area to “breathe”. Do not wear underpants at night but also avoid wearing tight

pants, swimming suits, biking shorts for long periods.

● Bathe or shower daily and gently pat the genital area and dry it with a clean towel.

Ecchymosis usually heals on its own within two or three weeks. The injury that causes the bruise may take longer to heal, especially if it involves broken bones.
These might be able to speed up the healing process with the following home remedies:

● Taking nonsteroidal anti-inflammatory medications, such as ibuprofen (Advil) to reduce painful swelling.

● Resting the affected area.

● Raising injured limbs above the heart to prevent painful swelling.

● Using a heat pack several times a day 48 hours after the injury or applying an ice pack in the first 24 to 48 hours after the initial injury.

REFERENCES

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Maitland K, Fraser JF. Fluid resuscitation with 0.9% saline alters haemostasis in an ovine model of endotoxemic shock. Thromb Res. 2019 Apr;176:39-45.

Costello RA, Nehring SM. Disseminated Intravascular Coagulation. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK441834/

Matsuda T. Clinical aspects of DIC--disseminated intravascular coagulation. Pol J Pharmacol. 1996 Jan-Feb;48(1):73-5. PMID: 9112631.

Okajima K, Sakamoto Y, Uchiba M. Heterogeneity in the incidence and clinical manifestations of disseminated intravascular coagulation: a study of 204 cases. Am J Hematol.

2000 Nov;65(3):215-22.

Martel, J. (2018, October 5). Low platelet count (thrombocytopenia). Healthline. from https://www.healthline.com/health/thrombocytopenia.
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