Students are to use the associated “Project Group” to review and prepare this case study for submission. Read the study and consider the presenting history, lab results and assessment findings. Discuss within your group to decide how to care for the patient and respond to the questions at the end of the 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. Upon 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.


  1. What type of shock is this, and what data supports that diagnosis?
  2. Identify two nursing interventions you would anticipate in this urgent situation.
  3. Explain Mrs. Rittenoff’s elevated White Blood Cell Count.
  4. What definitive treatment is indicated?
  5. Are there specific outcomes to observe with the normal saline fluid bolus?

No citations are needed.


Some Rubric

Some Rubric
This criterion is linked to a Learning OutcomeAccuracy, Clarity and Brevity The written responses are brief and to the point. No non-essential information is included while all pertinent data is present. Primary assessment of the case study is correct.100 pts Full Marks Clear and accurate responses are provided without extra information. All questions accurately addressed. 80 pts Most Credit No more than one response is missing vitally important data. No more than one response contains non-essential information to a significant degree. 60 pts Partial Credit No more than two responses are missing vitally important data. No more than two responses contain non-essential information to a significant degree. Primary identification of condition is incorrect. 0 pts No Credit Incorrect primary assessment of the case study. Not submitted on time. Multiple instances of missing vital information needed to address the situation in the case study.100 pts
Total Points: 100


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