instructions: read the case study and answer the 5 questions. Provided 1-2 sentences to each answers. SHOCK CASE STUDY:
Candace B. Rittenoff is a 63-year-old tax consultant with a history of hypertension and coronary artery disease. She had coronary artery stents placed in 2003 and takes aspirin 81 mg daily. As a result of her sedentary job and lifestyle, she had a deep vein thrombosis in 2008 and has been “on and off” warfarin since then. She is a poor historian and her husband states she often tries to “catch up” with missed medications.
She stated that for the past 2 weeks she was getting enoxaparin injections as a treatment of suspected deep vein thrombosis in the right leg. Current assessment does not indicate any suspicion of a clot. The enoxaparin dose is unknown. It was not clear if diagnostic tests were completed to rule out DVT, and she denies having any blood clots in her lungs. During this same time she continued to take warfarin. The physician had just increased the warfarin dose to 10 mg daily because of a refractory INR.
This morning, Mrs. Rittenoff awoke with pain in the left flank and left upper abdominal quadrant, which extended into the middle of the abdomen. She denies fever, nausea, vomiting, and diarrhea. She presented to the emergency department at noon. Initial laboratory results included:
White Blood Cells: 10,7000/microliter
Hemoglobin: 12.8 g/dl
Hematocrit: 39.5%
Platelets: 132,000/microliter
Mrs. Rittenoff is taken immediately to radiology for computerized tomography (CT) of the abdomen. The CT revealed a hematoma surrounding the left kidney and fluid in the upper abdomen around the pancreas that indicated possible hemorrhage.
She was immediately transferred to your critical care unit after the CT scan. Upon arrival her blood pressure (BP) was 70/30 mm Hg, but despite this, she was alert and oriented to person, place, and time; however, she complained of intermittent episodes of “lightheadedness.” Her oxygen requirements to maintain saturation above 90% were increased to 40% by Venturi mask. A central venous catheter was urgently placed and 3 liters of normal saline via rapid infusion (bolus) were administered along with 3 units of fresh frozen plasma and an anticoagulant reversal agent. An indwelling urinary catheter was inserted and returned only 50 mL of urine, and she has had no urine output since insertion.
Laboratory results after fluid resuscitation:
White blood cells: 13.36 103/microliter
Hemoglobin: 8.9 g/dL
Hematocrit: 30.1%
Platelets: 115,000/microliter
Mrs. Rittenoff continued to deteriorate. Opon re-examination, she was pale, cold, and clammy with no measurable BP, and her heart rate had increased to 150 beats per minutes. Her breathing was labored and pulse oximetry reading noted SaO2 to be 88% on 40% Venturi mask. The hemoglobin dropped from 12.8 to 8.9 g/dL. It is determined that Mrs. Rittenoff is in shock.
QUESTIONS FOR CONSIDERATION AND CARE PLANNING:
What type of shock is this, and what data supports that diagnosis?
Identify two nursing interventions you would anticipate in this urgent situation.
Explain Mrs. Rittenoff’s elevated White Blood Cell Count.
What definitive treatment is indicated?
Are there specific outcomes to observe with the normal saline fluid bolus.