Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)
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Outline
Lesson Objective for Disseminated Intravascular Coagulation (DIC)
- Understanding DIC Pathophysiology:
- Comprehend the underlying pathophysiological mechanisms of DIC, including the imbalance between coagulation and fibrinolysis.
- Identifying Risk Factors:
- Recognize and identify the risk factors that contribute to the development of DIC, such as sepsis, trauma, or obstetric complications.
- Symptom Recognition:
- Learn to recognize the clinical manifestations of DIC, including abnormal bleeding and clotting, petechiae, organ dysfunction, and laboratory abnormalities.
- Diagnostic Methods:
- Understand the diagnostic methods used to confirm DIC, including laboratory tests such as platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer levels.
- Intervention Strategies:
- Gain knowledge of nursing interventions and management strategies aimed at addressing DIC, including supportive measures, monitoring, and addressing the underlying cause.
Pathophysiology of Disseminated Intravascular Coagulation (DIC)
- Triggering Event:
- DIC often begins with an underlying trigger, such as severe sepsis, trauma, malignancy, obstetric complications, or other conditions that activate the coagulation system.
- Release of Tissue Factor:
- The triggering event leads to the release of tissue factor, initiating the extrinsic pathway of coagulation. Tissue factor activates factor VII, setting off a cascade of coagulation reactions.
- Excessive Thrombin Generation:
- Activation of the coagulation cascade results in an excessive generation of thrombin. Thrombin converts fibrinogen to fibrin, leading to the formation of microvascular thrombi throughout the circulation.
- Platelet Consumption:
- The formation of microvascular thrombi consumes platelets, resulting in thrombocytopenia. Decreased platelet count contributes to the bleeding manifestations observed in DIC.
- Fibrinolysis Activation:
- Simultaneously, the clotting process activates fibrinolysis, leading to the release of fibrin degradation products (FDPs) and D-dimers. Elevated D-dimer levels are characteristic of ongoing fibrinolysis.
- Microvascular Thrombosis and Organ Dysfunction:
- Widespread microvascular thrombosis and deposition of fibrin in small blood vessels lead to compromised blood flow, ischemia, and organ dysfunction. The consumption of clotting factors contributes to bleeding tendencies.
Etiology of Disseminated Intravascular Coagulation (DIC)
- Sepsis:
- DIC is commonly triggered by severe bacterial or viral infections, particularly sepsis. The release of endotoxins or exotoxins can activate the coagulation cascade.
- Trauma:
- Major trauma, such as extensive injuries or burns, can lead to widespread tissue damage and the release of procoagulant substances, initiating DIC.
- Obstetric Complications:
- Conditions such as abruptio placentae, amniotic fluid embolism, and severe preeclampsia can trigger DIC during pregnancy.
- Malignancy:
- Certain cancers, especially those associated with extensive tissue necrosis or metastasis, can activate the coagulation cascade and contribute to DIC.
- Systemic Inflammatory Response Syndrome (SIRS):
- Conditions causing a systemic inflammatory response, such as severe pancreatitis or major surgery, may lead to DIC due to the release of inflammatory mediators.
- Vascular Disorders:
- Conditions affecting blood vessels, including vasculitis or atherosclerosis, can disrupt vascular integrity and contribute to the initiation of DIC.
- Transfusion Reactions:
- Incompatible blood transfusions or massive blood transfusions can introduce foreign substances into the bloodstream, triggering an immune response and activating the coagulation cascade.
- Toxic Injuries:
- Exposure to toxins or chemicals, such as snake venom or certain medications, may induce a systemic response that activates coagulation pathways, leading to DIC.
Desired Outcomes for Disseminated Intravascular Coagulation (DIC)
- Normalization of Coagulation Parameters:
- Achieve and maintain a balance in coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and platelet count.
- Resolution of Underlying Cause:
- Identify and treat the underlying cause of DIC, addressing conditions such as sepsis, trauma, obstetric complications, malignancy, or systemic inflammatory response syndrome (SIRS).
- Prevention of Organ Dysfunction:
- Prevent or minimize organ dysfunction resulting from microvascular thrombosis and hemorrhage, focusing on organs such as the kidneys, lungs, and central nervous system.
- Maintenance of Tissue Perfusion:
- Ensure adequate tissue perfusion by managing fluid balance, hemodynamic stability, and oxygenation to prevent ischemia and multi-organ failure.
- Minimization of Bleeding Complications:
- Prevent and manage bleeding complications by carefully balancing anticoagulation and hemostasis, considering the risk of both thrombosis and hemorrhage in DIC patients.
Disseminated Intravascular Coagulation (DIC) Nursing Care Plan
Subjective Data:
- Chest pain
- Shortness of breath
- Pain in affected limb
- Headache
- Dizziness
- Double vision
Objective Data:
- Erythema
- Warmth of affected area
- Swelling
- Blood in urine or stool
- Petechiae
- Uncontrolled bleeding
Nursing Assessment for Disseminated Intravascular Coagulation (DIC)
- Clinical History:
- Obtain a detailed clinical history, including recent trauma, surgery, infections, or other underlying conditions that may contribute to the development of DIC.
- Bleeding Manifestations:
- Assess for signs of bleeding, such as petechiae, ecchymosis, mucosal bleeding, and prolonged bleeding from minor cuts or wounds.
- Clotting Manifestations:
- Evaluate for thrombotic manifestations, including deep vein thrombosis (DVT), pulmonary embolism (PE), or other clot-related complications.
- Skin Integrity:
- Inspect the skin for areas of necrosis or gangrene, which may occur due to microvascular thrombosis leading to impaired blood flow.
- Vital Signs:
- Monitor vital signs closely, paying attention to changes in blood pressure, heart rate, and respiratory rate, as DIC can lead to systemic instability.
- Laboratory Values:
- Review laboratory results, including platelet count, fibrinogen levels, prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer to confirm the diagnosis and assess severity.
- Organ Function:
- Assess organ function, especially renal and hepatic function, as DIC can lead to organ failure due to microvascular thrombosis and subsequent ischemia.
- Neurological Assessment:
- Evaluate neurological status for signs of altered mental status, confusion, or focal neurological deficits, which may indicate cerebral thrombosis or embolism.
- Fluid Balance:
- Monitor fluid balance closely, as DIC can lead to capillary leakage, resulting in hypovolemia and shock.
- Collaborate with Diagnostic Imaging:
- Collaborate with diagnostic imaging, such as ultrasound or CT scans, to identify thrombotic events and assess the extent of organ involvement.
Nursing Implementation for Disseminated Intravascular Coagulation (DIC)
- Administer Clotting Factors:
- Provide blood products, such as fresh frozen plasma or cryoprecipitate, to replace depleted clotting factors and support hemostasis.
- Monitor Fluid Balance:
- Implement strict intake and output monitoring to manage fluid balance. Adequate hydration helps prevent hypovolemia and supports organ perfusion.
- Administer Anticoagulants or Antiplatelet Agents:
- Depending on the underlying cause and severity, anticoagulants or antiplatelet medications may be administered to manage excessive clotting. This requires careful assessment of bleeding risk.
- Address Underlying Cause:
- Treat the primary cause of DIC, whether it’s sepsis, trauma, malignancy, or other triggers. Targeting the root cause is essential for resolving the coagulation abnormalities.
- Implement Bed Rest and Activity Restrictions:
- Promote bed rest and restrict activities to minimize the risk of bleeding. Patients with DIC are prone to bleeding complications, and careful monitoring of movements is essential.
- Provide Emotional Support:
- Offer emotional support to patients and their families, as DIC can be a critical and life-threatening condition. Discussing the condition, treatment options, and potential outcomes can help alleviate anxiety and stress.
Nursing Interventions and Rationales
- Assess and monitor respiratory status; note rate, rhythm, cyanosis; auscultate the lungs for areas of absent air movement
In both acute and chronic DIC, blood clots often form or travel to the lungs resulting in embolism. This will be evident by shortness of breath, cyanosis and complaints of chest pain
- Assess and monitor cardiac status; perform 12-lead ECG as indicated
Tachycardia, changes in blood pressure and decreased cap refill are signs of deteriorating cardiovascular function.
- Assess for changes in level of consciousness
Early signs of hypoxia include confusion and irritability; monitor for signs of stroke as blood clots may travel to the brain.
- Administer oxygen as necessary; monitor Arterial Blood Gas (ABG) and oxygen saturation
For optimal tissue perfusion, oxygen saturation should remain 90% or greater.
- Provide wound care and pressure for external bleeding
Simple procedures such as venipuncture and IV access can cause external bleeding which is severe. Apply more than usual pressure to assist with clotting.
- Assess amount and color of urine
Decreased perfusion to the kidneys may result in hematuria and decreased urination (output <30 mL/hr)
- Monitor for blood in stool; administer stool softeners to avoid straining during bowel movements
Dark blood in stool can indicate GI bleed, while bright red blood may indicate bleeding hemorrhoids or anal fissures.
- Monitor for hemoptysis or blood in suctioning
This is a common indicator of DIC. When suctioning secretions, observe for blood. Note any blood in emesis.
- Monitor diagnostic tests (labs):
- Platelet count- decreased
- PT / PTT- increased
- D-dimer level- markedly increased
Changes in these labs can help determine if treatment is effective.
- Initiate bleeding precautions; no razors, soft toothbrush, limit needle sticks as much as possible, limit BP readings
Minimize risks of bleeding from friction, injury or pressure. Observe for petechiae or purpura which can indicate
- Administer medications and blood products as necessary
Heparin may be used for chronic DIC when clotting is more of a problem; excessive blood loss may require transfusion; antibiotics are often given when infection or sepsis is the underlying factor.
Evaluation of Nursing Interventions for Disseminated Intravascular Coagulation (DIC)
- Coagulation Parameters:
- Regularly assess coagulation parameters, including PT, PTT, and platelet count, to evaluate the effectiveness of interventions in improving coagulation status.
- Hemodynamic Stability:
- Monitor the patient’s hemodynamic status, including blood pressure, heart rate, and perfusion, to determine if interventions have contributed to hemodynamic stability.
- Organ Function:
- Evaluate organ function through laboratory tests and clinical assessments to determine if the interventions have mitigated organ dysfunction associated with DIC.
- Bleeding Control:
- Assess the control of bleeding episodes and signs of hemorrhage, such as petechiae and ecchymosis, to determine if interventions have effectively managed coagulation abnormalities.
- Patient Response:
- Evaluate the overall response of the patient to the implemented nursing interventions, considering factors such as symptom improvement, decreased complications, and the patient’s overall well-being.
References
- https://emedicine.medscape.com/article/199627-treatment#d8
- https://www.nhlbi.nih.gov/health-topics/disseminated-intravascular-coagulation
- https://www.merckmanuals.com/home/blood-disorders/bleeding-due-to-clotting-disorders/disseminated-intravascular-coagulation-dic#v775325
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Transcript
Hey guys, let’s take a look at the care plan for disseminated intravascular coagulation also known as DIC. So in this lesson, we’ll briefly take a look at the pathophysiology and etiology of DIC. We’re also going to look at subjective and objective data, as well as nursing interventions and rationales.
Okay. Let’s look closer at DIC. So this is a condition where small blood clots form throughout the body’s small blood vessels. Serious bleeding can occur internally and externally because these clots use up platelets and clotting factors in the blood. Acute DIC develops within a few hours or days and leads to serious bleeding. Chronic DIC develops over weeks or months, and doesn’t usually lead to excessive bleeding, but the formation of more clots. So, there are several diseases and disorders that cause DIC generally derived from one of two processes: either an inflammatory process, sepsis or major trauma, or exposure of a procoagulant material in the blood like cancer, a brain injury, or an obstetric event. DIC can also occur due to a venomous snake bite.
Presentation and treatment depends on the cause and whether the DIC is acute or chronic. So, the desired outcome is going to be to treat the underlying cause, promote optimal gas exchange, restore clotting factors and reduce the risk of bleeding. Let’s take a look at some of the subjective and objective data that your patient with DIC may present with.
Now, remember subjective data are going to be things that are based on your patient’s opinions or feelings, and for DIC, they may express chest pain, shortness of breath, pain in the affected limb, a headache, dizziness, or even double vision.
Objective data may include erythema, warmth of the affected area, swelling, blood in the urine or the stool, BTKI, or of course, uncontrolled bleeding.
Okay, now onto the nursing interventions necessary when caring for a patient with DIC. Assess and monitor the respiratory status, noting the rates, the rhythm, and if there is any cyanosis. Both acute and chronic DIC blood clots often form or travel to the lungs resulting in an embolism. This will be evident by shortness of breath, cyanosis, or complaints of chest pain. Be sure to auscultate the lungs for areas of absence and air movement. You’re also going to want to assess and monitor the cardiac status (including a 12 lead EKG) as indicated, and of course, tachycardia and changes in blood pressure and decreased capillary refills are signs of deteriorating cardiovascular function. Next, assess for changes in level of consciousness because early signs of hypoxia include confusion and irritability and guys, monitor for signs of stroke as these clots can also travel to the brain. You’re also going to want to monitor arterial blood gases or ABG’s, and closely monitor oxygen saturation, administering oxygen when necessary keeping SATs greater than 90% for optimal tissue perfusion.
So with DIC, even the simplest of procedures, like if any puncture or an IV can cause external bleeding, which is severe, you must apply more pressure than normal to help with clotting in these situations. Assess the amount and color of your patient’s urine as there could be decreased perfusion to the kidneys, which may result in hematuria, and decreased urine output of less than 30 MLS per hour, as well as, monitor for blood in the stool. Now, dark blood in the stool can indicate a GI bleed, while bright red blood may indicate hemorrhoids or anal fissures. It’s important for these patients to administer stool softeners, to avoid straining during bowel movements. A common indicator of DIC is blood with suctioning, so make sure you are observing for blood when suctioning or with MSS. Monitoring labs like platelet counts, PT and PTT, and the D-dimer level are critical to help determine if treatment is effective.
So for DIC patients, it’s so important to minimize the risks of bleeding from friction, injury, or pressure. So, this means no razors, using a soft bristle toothbrush, limit needle sticks and BP readings as much as possible, and observe for petechiae and purpura. Heparin may be used for chronic DIC when clotting is more of a problem. Excessive blood loss may require a transfusion and antibiotics when sepsis or infection is the underlying factor.
Okay, guys, here is a look at the completed care plan for DIC. We love you guys. Now, go out and be your best self today and as always, happy nursing!
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