Disseminated intravascular coagulation (DIC) is a life-threatening hemostatic disarray in which bleeding and clotting occur simultaneously. It is also called consumptive coagulopathy and defibrination syndrome. The pathophysiology involves an overactivation of the clotting mechanisms with both enhanced fibrin production leading to small clots and fibrinolysis leading to enhanced bleeding. As its name implies, tiny clots accumulate in the microcirculation (capillaries) throughout the body, depleting the blood supply of its clotting factors. These microemboli interfere with blood flow and lead to ischemia and organ damage. As the clots begin to lyse, fibrin degradation products (FDPs) (which have an anticoagulant property of their own) are released. The FDPs, along with decreased levels of clotting factors in the bloodstream, lead to massive bleeding internally from the brain, kidneys, adrenals, heart, and other organs, or from any wounds and old puncture sites. Because disseminated intravascular coagulation is somewhat difficult to diagnose, the following definition may be helpful in understanding the disorder: a systemic thrombohemorrhagic coagulation disorder that is associated with well-defined clinical situations and laboratory evidence of coagulant activation, fibrinolytic activation, inhibitor consumption, and biochemical evidence of endorgan damage. Morbidity and mortality depend on the underlying disease that initiates disseminated intravascular coagulation and the severity of coagulopathy. In people who are severely injured, the presence of disseminated intravascular coagulation generally doubles the mortality rate.
Disseminated intravascular coagulation always occurs in response to another type of disease or trauma. Disseminated intravascular coagulation is usually an acute syndrome, although it may be chronic in patients with cancer or more longstanding conditions. Sepsis is the most common cause of disseminated intravascular coagulation, with a prevalence of 7 to 50%. Conditions that may precede its development are cardiac and peripheral vascular disorders, transfusion reactions, sepsis, viremias, liver disease, leukemia, metastatic cancer, burn injuries, and obstetric complications (abruptio placentae, pregnancy-induced hypertension, saline abortion, amniotic fluid embolism, or a retained dead fetus). It is not known how these disorders trigger the onset of disseminated intravascular coagulation, but they activate the intrinsic or extrinsic pathway of the coagulation cascade. Some experts suggest that these disorders cause a foreign protein to be released into the circulation and that the vascular endothelium is injured. Others note that one of the following clinical situations needs to be present in order for disseminated intravascular coagulation to occur: arterial hypotension, hypoxemia, academia, and stasis of capillary blood flow.
Nursing care plan assessment and physical examination
Obtain a history specific to the precipitating disorder. If the patient is alert, ask if he or she has any chest, joint, back, or muscle pain, which is often severe in disseminated intravascular coagulation. Recognize that the patient may be confused and disoriented as a result of blood loss or the underlying condition, so that historic information may not be accurate.
Assess the patient’s skin for any petechiae, ecchymoses, hematoma formation, epistaxis, bleeding from wounds, vaginal bleeding in the labor or postpartum patient, hematuria, conjunctival hemorrhage, and hemoptysis. Bruising can occur anywhere in the body. In addition, assess the patient’s skin for bleeding or oozing at any intravenous (IV), intramuscular (IM), or epidural sites. Assess the patient’s vital signs. If the patient is hypovolemic, expect to find a decreased blood pressure, rapid thready pulse, and increased respiratory rate. The patient may be restless, agitated, and confused. Measure the abdominal girth to obtain a baseline for further assessments. Note the presence of oliguria and compare current urine output with previous readings.
Patients may feel a sense of “impending doom,” and the family is probably fearful of losing a loved one. This situation is intensified if the patient is a young pregnant or newly delivered mother. Note that increased blood or bleeding is associated with death and dying for many people; the visible presence of multiple bleeding or oozing sites and the need for multiple transfusions may also be a source of anxiety.
Nursing care plan primary nursing diagnosis: Fluid volume deficit related to blood loss.
Nursing care plan intervention and treatment
Since disseminated intravascular coagulation always occurs in association with another condition, medical treatment focuses on correcting the underlying disorder. In addition, the physician seeks to return the patient to normal hemostasis. Active bleeding is managed by blood component therapy. To ascertain the success of cell and factor replacement, constant surveillance of laboratory values is critical to determine which blood components should be administered. In general, packed red blood cells are used to improve oxygen delivery by increasing the hemoglobin content of the blood. Fresh-frozen plasma replaces many of the clotting factors, whereas cryoprecipitate is the best source of fibrinogen and factors V, VIII, and XIII. Platelet transfusion is used when the platelet count falls below 100,000/mm3.
If the patient is critically ill, the physician may place a pulmonary artery catheter (PAC) to monitor the patient’s hemodynamic status. Note that increased bleeding tendencies make the insertion time of central access devices important; central catheters such as a PAC should be placed when the coagulation profile has been corrected with blood component therapy to prevent dangerous bleeding into the cardiopulmonary system.
If the patient is pregnant, fetal monitoring is continuous; notify the physician of late decelerations, decreased variability, or bradycardia. Keep the patient on her left side, and administer oxygen by mask at a rate of 10 L per minute. Turn and reposition the patient frequently and gently to avoid further bleeding. The goal is to keep the fetus oxygenated while stabilizing the mother so that a cesarean section can be done.
When a bleeding disorder occurs in addition to another condition, the patient’s and significant others’ coping skills and resiliency may be at a low point. During this time, the patient and significant others need accurate information, honest reports about the patient’s condition and prognosis, and an attentive nurse to listen to their concerns. Provide emotional support and educate them as to the interventions and expected outcomes. Help them understand the severity of the condition and the treatments; do not present false hopes. Offer to call a chaplain or religious counselor if needed. The patient is usually maintained on complete bedrest. Pad the side rails to help prevent injury. Reposition the patient every 2 hours, and provide skin care. Gently touch the skin when repositioning and bathing; vigorous rubbing could dislodge a clot and initiate fresh bleeding. Crusted blood can be gently cleaned with a mixture of hydrogen peroxide and water and cotton. If the patient has experienced hemarthrosis (bleeding into the joints), the condition is very painful. Manipulate any joint gently and with great care to minimize discomfort and to limit further bleeding.
Communicate to all healthcare personnel coming in contact with the patient about her or his bleeding tendency. Place notations on the chart cover and at the head of the bed to alert caregivers to the patient’s bleeding condition. Keep all venipunctures to a minimum, and hold pressure to any puncture site for at least 10 minutes.
Nursing care plan discharge and home health care guidelines
Teach the patient and significant others about the disorder and that it is unlikely that it will recur in the future. If the patient required blood component therapy, provide information about the risk of hepatitis or human immunodeficiency virus (HIV) transmission. Check with the patient’s obstetrician to determine if the patient can nurse the infant and resume unprotected sexual relations. Provide discharge instructions related to the patient’s primary diagnosis. Teach the patient to notify the physician of any uncontrollable bleeding or syncope.