Disseminated intravascular coagulation (DIC) is a life-threatening condition that requires immediate medical attention. As a nurse, it is crucial to understand the nursing care plans and nursing diagnosis for DIC to provide the best care for patients. This guide provides a comprehensive overview of DIC nursing care plans and nursing diagnosis, including common symptoms, nursing management, nursing interventions, and treatment options.
What is Disseminated Intravascular Coagulation?
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 micro clots 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 injuries such as from malignancy, trauma, or obstetrical complications. DIC may present as an acute or chronic condition.
Essential medical management of DIC is primarily aimed at treating the underlying cause, managing complications from both primary and secondary causes, supporting organ function, stopping abnormal coagulation, and controlling bleeding. Morbidity and mortality depend on the underlying cause and severity of coagulopathy.
Nursing Care Plans
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, and prevention of complications.
Here are four (4) nursing care plans (NCP) and nursing diagnoses for patients with disseminated intravascular coagulation:
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.
- 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)
- 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.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 6 Care Plans UPDATED!
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans