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Chapter: Medical Surgical Nursing: Assessment and Management of Patients With Hematologic Disorders

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

Nurses need to be aware of patients who are at risk for 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.

 

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