PT/INR

PostOpPrincess, BSN, RN · Oct 18, 2009

Well....

You may have overlooked his VS as the initial, early indicator of a change in hemodynamic status. You were very focused on his INR...

Did you do a full head-to toe assessment?

Did you review his whole set of labs?

What did he look like? Neuro? Cardiac? Respiratory.

There are early signs to tell you if someone is having a problem......sepsis and coagulopathies usually go hand in hand and are pretty late indicators.

Pat_Pat RN · Oct 18, 2009

Here's a link I found with some info on Sepsis: http://ssc.sccm.org/sepsis/what_you_should_know

Did he have a fever? That BP isn't too low, but depending on what the normal is, that could be low for him. Sepsis is tricky.

Good luck!

Pat

chellelynn25 · Oct 18, 2009

The only lab he had drawn that day was the PT/INR I reviewed previous labs with the MD all of them were pretty norm. Did a head to toe, vitals he was sating in the 90s on RA no sob didn't became cyanotic untill all of a sudden. his pressure usually runs around there. PERL grasps equal, no n/v/d no temp. lungs sounds decreased in the bases. no acute distress untill he became cyanotic.

Pat_Pat RN · Oct 18, 2009

Maybe another PE d/t sepsis, that would explain the cyanosis and the sudden onset of it.

This reminds me of the case studies that we were doing for a while...whatever happened to that?

SunnyAndrsn · Oct 18, 2009

I don't see where you missed anything. You assessed pt. after getting the critcal PT/INR, and as you've said--the pt's history tells you he's a walking time bomb. With cirrhosis, there is so much that can go wrong suddenly. You took all appropriate steps, sounds like you had good nursing interventions, and you got the pt. to the hospital when he presented.

I had a pt. become septic very quickly as well. She had fluctuating O2 sats, which was her baseline r/t COPD. We were weaning her off of O2. On a Saturday she had O2 sats at 99%, VSS, denied pain, SOB, no altered mental status. Complained of a bit of a sore throat that she attributed to the O2 being on all night. She had similar complaints in the past....

Sunday her sats were 89% on room air, put her back on O2, no change in how she was feeling, no change in VS, activity level, etc. LS diminished, her baseline.

Monday I sent her to the hospital, we managed to get her sats up to the high 80's on 4Ls, when she was typically on 1-2. She was septic of unknown origin, and died a week later.

Still haven't gotten over that one. I spent a lot of time talking to her MD and he assured me that it was sudden, there was nothing else to indicate a problem, and her labs two days prior showed no indication of what was to come.

]Was in the middle of my 8 am med pass when I get a call from the lab with a critical value. A res of mine had a PT>100 and INR>12.5. He was on 7.5 of coumadin q day. Anywas I call the MD, get an order for Vitamin K, give it. I Res has no s/s of bleeding. VSS pulse is kinda of tachy but it always is. Anyways the MD wanted the PT/INR rechecked at 1pm. The phleb comes down from the hospital. Sticks him three times and doesn't get enough to fill the tube. His blood was clotting off in the tube. Another phleb comes down sticks him 2 more times and barely gets enough blood for the lab. Still at this point in time he has no s/s of anything. He's a 50 year old man who has hx of PE, PAD, MI, CHF, COPD , alcoholism, drug abuse and has cirrhosis. Hes a walking time bomb. I call the MD to let him know that the lab was late in getting in drawn b/c they had such a hard time sticking him. (they've never had any issues before) The doc is like I hope they ( the lab) didn't mess up with the results, I agree with him and he tells me just to keep monitoring him, call with the lab ASAP when I get it back. With is PT/INR being that high, even with the K is blood should have not become that way. At least that is my opinion. I know more than hang up the phone with the doc and am summoned to thr res room by one of the CNAs. He's turning cyanotic, diaphoretic and is respirations are 32, B/P 106/76 he's sat'ing at 92% tho. I put him on some O2 which he promptly rips off, I'm boggled. This is approx 2 pm. I've now been dealing with this all day. He was not in any kind of distress prior to this. He's been talking, eating lunch, etc. Call the MD back and I end up sending him to the ER. After I get him off to the hosipital, my shift is over. I call a friend of mine working 3-11 to see if they have heard anything about him. She tells me that his labs came back still high but not like they were and that he had been admitted to the hospital as septic. Did I miss something somewhere? I just don't understand. My DON says I did fine that I took the right steps. As anyone else ever had a situation like this?

CynicallyVexed · Oct 18, 2009

If he is truly septic he can be going through DIC which is making his PT/INR be crazy like that. DIC and Sepsis go hand in hand, especially with patients with multi-system organ failure like he is. There's no possible way of you actually knowing this unless if you have seen patients go through this before.

You didn't miss anything. Without the VS and just having the PT/INR and having his history I would suggest he had a liver problem that's throwing off his clotting factors first before suspecting Sepsis & DIC.

You did everything correct. When his RR increased and BP dropped one would think he might have been having a PE, which he may have formed with the DIC. Nothing you could have done about that. Sending him to the ER and staying on top of the doctor is everything you could have done.

Sepsis is funny like that. When you have enough pathogens in your blood stream your body attempts to "clot' them off in order to get rid of them. You may have caught it just in time too cause he still had allot of his clotting factors in place where the lab couldn't stick him to draw. Which is good. If he would have spent another day or two like that who would have stroked out, thrown a PE, or bled out from every where possible.

Pat_Pat RN · Oct 18, 2009

If he is truly septic he can be going through DIC which is making his PT/INR be crazy like that. DIC and Sepsis go hand in hand, especially with patients with multi-system organ failure like he is. There's no possible way of you actually knowing this unless if you have seen patients go through this before.
You didn't miss anything. Without the VS and just having the PT/INR and having his history I would suggest he had a liver problem that's throwing off his clotting factors first before suspecting Sepsis & DIC.
You did everything correct. When his RR increased and BP dropped one would think he might have been having a PE, which he may have formed with the DIC. Nothing you could have done about that. Sending him to the ER and staying on top of the doctor is everything you could have done.
Sepsis is funny like that. When you have enough pathogens in your blood stream your body attempts to "clot' them off in order to get rid of them. You may have caught it just in time too cause he still had allot of his clotting factors in place where the lab couldn't stick him to draw. Which is good. If he would have spent another day or two like that who would have stroked out, thrown a PE, or bled out from every where possible.

^ Yeah, I thought of that too......