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 ADMINISTRATION
Generic name: Clindamycin(RX) Indication:
● Treatment of serious infections
caused by susceptible anaerobic
bacteria, as well as susceptible
Brand name: Cleocin staphylococci, streptococci, and
pneumococci.
● Does not penetrate the blood/brain
barrier in therapeutically effective
quantities.
Classification: Antibiotics
Mode of action:
● Clindamycin works primarily by
Sub-Classification: Lincosamide binding to the 50s ribosomal subunit
of bacteria. This agent disrupts
protein synthesis by interfering with
the transpeptidation reaction, which
thereby inhibits early chain
Dosage: 600 to 1,200 g per day divide every 6 elongation.
hours
DRUG EFFECTS
Side effects:
● Any change in bowel movements;
● Severe stomach pain, diarrhea that is
watery or bloody;
● Little or no urination; or a metallic taste
in your mouth
● Nausea, vomiting, mild skin rash; or
● Vaginal itching or discharge
Adverse effect:
● Hypersensitivity Reactions -
Maculopapular rash and urticaria have
been observed during drug therapy.
Generalized mild to moderate
morbilliform-like skin rashes are the
most frequently reported of all adverse
reactions.
● Gastrointestinal -
Antibiotic-associated
DRUG NURSING CONSIDERATIONS
● Monitor signs of pseudomembranous
colitis, including diarrhea, abdominal
pain, fever, pus or mucus in stools,
and other severe or prolonged GI
problems (nausea, vomiting,
heartburn). Notify physicians or
nursing staff immediately of these
signs.
● Assess dizziness or vertigo that
might affect gait, balance, and other
functional activities. Report balance
problems and functional limitations to
the physician and nursing staff, and
caution the patient and
family/caregivers to guard against
falls and trauma.
● Assess heart rate, ECG, and heart
sounds, especially during exercise.
Report any rhythm disturbances or
symptoms of increased arrhythmias,
including palpitations, chest

Route: Intravenous Infusion
Frequency: Continuous
Preparations:
● A single 1 hour IV infusion greater than
1,200 mg is not recommended
● Intravenous doses should be diluted
and administered as an infusion over
10 to 60 minutes, at a rate not
exceeding 30 mg/min.
● Clindamycin for intravenous use must
be diluted prior to administration
● The concentration of clindamycin in
diluent for IV infusion should not
exceed 18 mg/mL.
● May give continuous IV infusion
instead of intermittent after the first
dose has been given by rapid IV
infusion.
Pharmacokinetics:
● Absorption
○ When the equivalent of
300mg of clindamycin is
injected intramuscularly, a
mean peak plasma
concentration of 6
microgram/ml is achieved
within three hours; 600mg
gives a peak concentration
of 9 microgram/ml. In
children, peak concentration
may be reached within one
hour. When the same doses
are infused intravenously,
peak concentrations of 7
and 10 micrograms per ml
respectively are achieved by
the end of infusion.
colitis,pseudomembranous colitis,
abdominal pain, nausea, and vomiting.
The onset of pseudomembranous
colitis symptoms may occur during or
after antibacterial treatment. An
unpleasant or metallic taste has been
reported after intravenous
administration of the higher doses of
clindamycin phosphate.
● Local Reactions - Injection site
irritation, pain, induration and sterile
abscess have been reported after
intramuscular injection and
thrombophlebitis after intravenous
infusion. Reactions can be minimized
or avoided by giving deep
intramuscular injections and avoiding
prolonged use of indwelling
intravenous catheters.
discomfort, shortness of breath,
fainting, and fatigue/weakness.
● Monitor injection site for pain,
swelling, and irritation. Report
prolonged or excessive injection site
reactions to the physician.
● Assess blood pressure periodically,
and compare to normal values.
Report low blood pressure
(hypotension), especially if the
patient experiences dizziness,
fatigue, or other symptoms.
 ● Distribution
Special Considerations:
● Clindamycin should be given to official
guidance on the appropriate use of
antibacterial agents.
● Elimination
○ Clindamycin is widely
distributed in body fluids and
tissues to the bone . It
diffuses across the placenta
into the foetal circulation and
appears in breast milk. High
concentrations occur in bile.
It accumulates in leukocytes
and macrophages. Over
90% of clindamycin in the
circulation is bound to
plasma proteins.
○ The half-life is 2 to 3 hours,
although this may be
prolonged in pre-term
neonates and patients with
severe renal impairment.
○ About 10% of the drug is
excreted in the urine as
active drug or metabolites
and about 4% in the faeces;
the remainder is excreted as
● Musculoskeletal - Polyarthritis cases
have been reported.
Contraindication:
● Clindamycin is contraindicated in
patients with a history of
pseudomembranous colitis or
ulcerative colitis. Hypersensitivity to
clindamycin, lincomycin, or formulation
components.
Food and Drug interaction:
● It's recommended that antibiotics are
not taken with dairy products such as
cheese, milk, butter, and yogurt should
not be consumed until 3 hours after a
dose of antibiotics is taken. Likewise,
juices or supplements containing
calcium may also reduce effectiveness.
● It is recommended to take with a full
glass of water. Clindamycin may cause
esophageal irritation if the dosage form
becomes lodged.
 inactive metabolites.
Excretion is slow and takes
place over several days. It is
not effectively removed from
the blood by dialysis.
Pharmacodynamics:
● Clindamycin exerts its bacteriostatic
effect via inhibition of microbial
protein synthesis. Clindamycin has a
relatively short Tmax and half-life
necessitating administration every
six hours to ensure adequate
antibiotic concentrations.
Therapeutic effect:
● Bactericidal or bacteriostatic,
depending on susceptibility and
concentration.
● Take with or without food. Food does
not appreciably alter the absorption of
clindamycin.
● Alcohol: Drinking alcohol cannot affect
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.
● Drug:
○ Abiraterone and Acalabrutinib
cab decreased the metabolism
of Clindamycin.
○ Erythromycin: Clindamycin and
another antibiotic called
erythromycin can compete
against each other. This
competition may decrease the
effectiveness of antibiotic
medications. Therefore,
patients should not take them
together.
Generic Name: Heparin(Rx)
Brand Name: Lovenox
Classification: Glycosaminoglycan
Sub-Classification: Anticoagulants
Dosage: 20,000 to 40,000 units per 24 hour
Mode of Action:
Indication
● Prophylaxis and treatment of venous
thromboembolism and pulmonary
embolism;
● Atrial fibrillation with embolization;
● Treatment of acute and chronic
consumptive coagulopathies
(disseminated intravascular
coagulation);
● Prevention of clotting in arterial and
cardiac surgery;
● Prophylaxis and treatment of
peripheral arterial embolism;
● Anticoagulant use in blood
transfusions, extracorporeal
circulation, and dialysis procedures.
● Heparin binds to the enzyme
inhibitor antithrombin III (AT),
Side Effects
● Easy bleeding and bruising;
● Pain, redness, warmth, irritation, or
skin changes where the medicine was
injected;
● Itching of your feet; or
● Bluish-colored skin.
● In patients with DVT, watch for signs
Adverse Effects:
● Hemorrhage - Hemorrhage is the chief
complication that may result from
heparin therapy. Gastrointestinal or
urinary tract bleeding during
● Assess for signs of bleeding and
anticoagulant therapy may indicate the
presence of an underlying occult
lesion. Bleeding can occur at any site
but certain specific hemorrhagic
complications may be difficult to detect:
○ Adrenal hemorrhage, with
resultant acute adrenal
insufficiency, has occurred with
● Monitor symptoms of deep
veinthrombosis (DVT) (pain,
swelling, warmth, redness) to
determine if drug therapy is effective
in preventing or reducing venous
thrombosis. Request or administer
objective tests (Doppler ultrasound)
if symptoms increase.
of pulmonary embolism, such as
shortness of breath, chest pain,
cough, and bloody sputum. Notify
physician or nursing staff
immediately if these signs occur.
hemorrhage, including bleeding
gums, nosebleeds, unusual bruising,
black/tarry stools, hematuria, and fall
in hematocrit or blood pressure.
Notify physician or nursing staff
immediately if heparin causes
excessive anticoagulation.
Route: Intravenous Injection
Frequency: Continuous
Pharmacokinetics:
● Absorption
Preparations:
● Recommended infusion concentration
for most patients is 25,000 units in 500
mL D5W (50 units/mL premixed
infusion solution)
● IV injection may be given undiluted or
diluted in 50-100 mL NS or D5W
● Infusion: Dilute in NS, D5W, or other
compatible fluid
● Distribution
● Continuous IV therapy is preferred
because intermittent IV therapy
produces a higher incidence of
bleeding abnormalities
● Invert IV bag at least 6 times to ensure
mixing and prevent pooling of
causing a conformational change
that results in its activation through
an increase in the flexibility of its
reactive site loop. The activated AT
then inactivates thrombin, factor Xa
and other proteases.
○ Heparin is not absorbed
through the gastrointestinal
tract and therefore
administered via parenteral
route. Peak plasma
concentration and the onset
of action are achieved
immediately after
intravenous administration.
○ Heparin is highly bound to
antithrombin, fibrinogens,
globulins, serum proteases
and lipoproteins. The
volume of distribution is 0.07
L/kg.
heparin therapy, including fatal
cases.
○ Ovarian (corpus luteum)
hemorrhage developed in a
number of women of
reproductive age receiving
short- or long-term
anticoagulant therapy.
○ Retroperitoneal hemorrhage.
● HIT and HITT, including delayed onset
cases [see WARNINGS AND
PRECAUTIONS].
● Hypersensitivity - Generalized
hypersensitivity reactions have been
reported with chills, fever, and urticaria
as the most usual manifestations, and
asthma, rhinitis, lacrimation, headache,
nausea and vomiting, and
anaphylactoid reactions, including
shock, occurring more rarely. Itching
and burning, especially on the plantar
side of the feet, may occur [see
WARNINGS AND PRECAUTIONS].
● Elevations of serum
● Monitor signs of allergic reactions
and anaphylaxis, including
pulmonary symptoms (tightness in
the throat and chest, wheezing,
cough, dyspnea) or skin reactions
(rash, pruritus, urticaria). Notify
physician or nursing staff
immediately if these reactions occur.
● Be alert for acute arterial or venous
thrombosis caused by
heparin-induced thrombocytopenia
(HIT). In certain patients, heparin
initiates an immune reaction where
antibodies attack circulating
platelets. Although most cases of
HIT are minor and asymptomatic,
some patients may experience life-
or limb-threatening platelet clots,
resulting in myocardial infarction,
ischemic stroke, acute leg ischemia,
or venous thromboembolism. HIT
can occur during and up to several
weeks after heparin therapy. Any
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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