Disseminated intravascular coagulation

63 Disseminated intravascular coagulation




Overview/pathophysiology


Disseminated intravascular coagulation (DIC) is an acute coagulation disorder characterized by paradoxical clotting and hemorrhage. The sequence usually progresses from massive clot formation, depletion of clotting factors, and activation of diffuse fibrinolysis to hemorrhage. DIC occurs secondary to widespread coagulation factors in the bloodstream caused by extensive surgery, burns, shock, sepsis, neoplastic diseases, or abruptio placentae; extensive destruction of blood vessel walls caused by eclampsia, anoxia, or heat stroke; or damage to blood cells caused by hemolysis, sickle cell disease, or transfusion reactions. While clotting and bleeding occur simultaneously, organ failure related to thromboses of vital organs (e.g., renal, pulmonary) is usually the primary life-threatening concern. Prompt assessment of the disorder can result in a good prognosis. Usually, affected patients are transferred to the intensive care unit (ICU) for careful monitoring and aggressive therapy. DIC may be classified as low-grade (compensated or chronic) or fulminant (acute).



Health care setting


Acute care/critical care unit



Assessment




Clinical indicators:


Bleeding of abrupt onset; oozing from venipuncture sites or mucosal surfaces; bleeding from surgical sites; and presence of hematuria, blood in stool (melena or hematochezia), spontaneous ecchymosis (bruising), petechiae, purpura fulminans, pallor, or mottled skin. The patient also may bleed from the vagina (menometrorrhagia), nose (epistaxis), and mucous membranes. Joint pain and swelling may signal bleeding into joints. Complaint of headache or mental status changes may indicate intracranial hemorrhage and/or stroke. Symptoms of hypoperfusion can occur, including decreased urine output and abnormal behavior.



Physical assessment:


Abdominal assessment may reveal signs of gastrointestinal (GI) bleeding, such as guarding; distention (increasing abdominal girth measurements); hyperactive, hypoactive, or absent bowel sounds; and a rigid, boardlike abdomen. With significant hemorrhage, patients may exhibit the following: systolic blood pressure (SBP) less than 90 mm Hg and diastolic blood pressure (DBP) less than 60 mm Hg; heart rate (HR) greater than 100 bpm; peripheral pulse amplitude 2+ or less on a 0-4+ scale; respiratory rate (RR) greater than 22 breaths/min; shortness of breath; urinary output less than 30 mL/hr; secretions and excretions positive for blood; cool, pale, clammy skin; lack of orientation to person, place, and time; or changes in mental status.



Risk factors:


Infection, burns, trauma, hepatic disease, hypovolemic shock, severe hemolytic reaction, malignancy, obstetric complications, and hypoxia.



Diagnostic tests




Serum fibrinogen:


Low because of abnormal consumption of clotting factors in the formation of fibrin clots.



Platelet count:


Less than 250,000/mm3.



Fibrin split products:


Increased, indicating widespread dissolution of clots. Fibrinolysis produces fibrin split products (FSPs), also known as fibrin degradation products (FDPs), as an end product.



D-dimers:


The byproducts of fibrinolysis, D-dimers are increased in DIC and, along with increased FDPs, are considered diagnostic of DIC.



Prothrombin time:


Normal, low, or possibly increased because of depletion of clotting factors.



Partial thromboplastin time:


Normal, low, or possibly high because of depletion of clotting factors.



Peripheral blood smear:


Shows fragmented red blood cells (RBCs; schistocytes).





Nursing diagnoses:


Ineffective peripheral tissue perfusion (or risk for same)


Risk for ineffective cerebral tissue perfusion


Risk for ineffective renal tissue perfusion


Risk for decreased cardiac tissue perfusion

related to coagulation/fibrinolysis processes


Desired Outcome: Following treatment, patient has adequate tissue perfusion as evidenced by blood pressure (BP) 90/60 mm Hg or greater and HR 100 bpm or less (or within patient’s baseline range); peripheral pulse amplitude 2+ or greater on a 0-4+ scale; urinary output 30 mL/hr or more; equal and normoreactive pupils; normal/baseline motor function; orientation to person, place, and time; and no mental status changes.









ASSESSMENT/INTERVENTIONS RATIONALES

Assess for coagulation and bleeding as follows:
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Disseminated intravascular coagulation

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