Nursing Process: The Patient With Disseminated Intravascular Coagulation (DIC)

NURSING PROCESS: THE PATIENT WITH DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Assessment

Nurses need to be aware of patients who are at risk for DIC. Sep-sis and acute promyelocytic leukemia are the most common causes of DIC. Patients need to be assessed thoroughly and fre-quently for signs and symptoms of thrombi and bleeding and monitored for any progression of these signs (see Table 33-7).

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, major nursing diagnoses for the pa-tient with DIC may include the following:

•        Risk for deficient fluid volume related to bleeding

•        Risk for impaired skin integrity related to ischemia or bleeding

•        Potential for excess fluid volume related to excessive blood/ factor component replacement

•        Ineffective tissue perfusion related to microthrombi

•         Anxiety and fear of the unknown and possible death

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Collaborative problems include the clinical conditions that pre-cipitated the DIC. Based on the assessment data, potential com-plications may include:

•          Renal failure

•          Gangrene

•          Pulmonary embolism or hemorrhage

•          Altered level of consciousness

•          Acute respiratory distress syndrome

•          Stroke

Planning and Goals

Major patient goals include maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, en-hanced coping, and absence of complications (see Plan of Nurs-ing Care).

Nursing Interventions

See Plan of Nursing Care: The Patient with Disseminated In-travascular Coagulation.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Despite aggressive measures, the lack of renal perfusion may result in acute renal failure, sometimes necessitating dialysis. Placement of a large-bore dialysis catheter is extremely hazardous in this pa-tient population and should be accompanied by adequate platelet and plasma transfusions.

Evaluation

See the Plan of Nursing Care for evaluation and expected out-comes for the patient with DIC.