Disseminated intravascular coagulation (DIC) is a coagulation disorder that prompts overstimulation of the normal clotting cascade and results in simultaneous thrombosis and hemorrhage. The formation of microclots affects tissue perfusion in the major organs, causing hypoxia, ischemia, and tissue damage. Coagulation occurs in two different pathways: intrinsic and extrinsic. These pathways are responsible for the formation of fibrin clots and blood clotting, which maintains homeostasis. In the intrinsic pathway, endothelial cell damage commonly occurs because of sepsis or infection. The extrinsic pathway is initiated by tissue injury such as from malignancy, trauma, or obstetrical complications. DIC may present as an acute or chronic condition.
An essential medical management of DIC is primarily aimed at treating the underlying cause, managing complications from both primary and secondary cause, supporting organ function, and stopping abnormal coagulation and controlling bleeding. Morbidity and mortality depend on underlying cause and severity of coagulopathy.
The following are the common nursing care planning and goals for clients with DIC: maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, prevention of complications.
Here are four (4) nursing care plans (NCP) and nursing diagnosis for patients with disseminated intravascular coagulation:
Impaired Gas Exchange
May be related to
- Altered oxygen-carrying capacity of blood
Possibly evidenced by
- Abnormal arterial blood gases (ABGs)
- Abnormal breathing (rate, depth, and rhythm)
- Client will maintain optimal gas exchange, as evidenced by ABGs within 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.
|Assess for changes in the level of consciousness.||Early signs of cerebral hypoxia are restlessness and irritability; later signs are confusion and somnolence.|
|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 the acidosis with the shock state. The development of hypoventilation indicates that immediate ventilator support is needed.|
|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.|
|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.|
|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.|
|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.|
|Change the client’s positioning every 2hours, and perform chest physiotherapy.||These maneuvers facilitate the movement and drainage of secretions.|
|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.|
|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.|
|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.|
|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 to the client.|
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Hematologic and Lymphatic Care Plans
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