4 Disseminated Intravascular Coagulation Nursing Care Plans

Impaired Gas Exchange

In Disseminated intravascular coagulation (DIC), the abnormal blood clotting can lead to the consumption of clotting factors and platelets, which can cause bleeding and reduced oxygen-carrying capacity of the blood. This can result in impaired gas exchange, as there is not enough oxygen being transported to the tissues.

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• The altered oxygen-carrying capacity of the blood

Possibly evidenced by

• Abnormal arterial blood gases (ABGs)
• Abnormal breathing (rate, depth, and rhythm)
• Confusion
• Dyspnea
• Hypercapnia
• Hypoxemia
• Hypoxia
• Irritability
• Restlessness
• Somnolence

Desired Outcomes

• The client will maintain optimal gas exchange, as evidenced by ABGs within the client’s usual range; oxygen saturation of 90% or greater; alert, responsive mentation or no further reduction in the level of consciousness; and relaxed breathing and baseline HR for the client.

Nursing Assessment and Rationales

1. Assess for changes in the level of consciousness.
Early signs of cerebral hypoxia are restlessness and irritability; later signs are confusion and somnolence.

2. Assess the respiratory depth, rate, and rhythm.
The client will adapt breathing patterns over time to facilitate gas exchange. Rapid, shallow respirations may result from hypoxia or from acidosis with the shock state. The development of hypoventilation indicates that immediate ventilator support is needed.

3. Assess the client’s breath sounds. Assess cough for signs of bloody sputum.
Changes in breath sounds may reveal the cause of impaired gas exchange. Hemoptysis is an indication of bleeding in the respiratory tract.

4. Assess for tachycardia, shortness of breath, and use of accessory muscles.
These signify an increased work of breathing. With initial hypoxia, HR increases. The use of accessory muscles increases chest excursion to facilitate effective breathing.

5. Monitor oxygen saturation and assess arterial blood gases (ABGs).
Pulse oximetry is a useful tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater. Increasing PaCo2 and decreasing PaO2 are signs of hypoxemia and respiratory acidosis.

Nursing Interventions and Rationales

1. Provide reassurance and allay anxiety by staying with the client during the acute episodes of respiratory distress.
Anxiety increases dyspnea, the work of breathing, and the respiratory rate.

2. Change the client’s positioning every 2 hours, and perform chest physiotherapy.
These maneuvers facilitate the movement and drainage of secretions.

3. Position the client in a high-Fowler’s position as indicated.
An upright position allows for adequate diaphragmatic and lung excursion and promotes optimal lung expansion.

4. Assist with coughing or suction as indicated.
Productive coughing is the most effective way to remove moist secretions. If the client is unable to perform independently, suctioning may be needed to promote airway patency and reduce the work of breathing.

5. Maintain an oxygen administration device as ordered.
The appropriate amount of oxygen must be delivered continuously so that the client maintains an oxygen saturation of 90% or greater.

6. Anticipate the need for intubation and mechanical ventilation.
Early intubation and mechanical ventilation are recommended to prevent full decompensation of the client. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation for the client.