Disseminated Intravascular Coagulation (DIC) is a serious, potentially life-threatening condition characterized by the widespread activation of the coagulation cascade, leading to the formation of blood clots throughout the small blood vessels in the body.
This process simultaneously depletes clotting factors and platelets, which can result in severe bleeding. DIC is not a primary illness but rather a complication of various underlying conditions.
Causes of DIC can be classified into several categories:
- Sepsis and severe infections
- Trauma (especially brain injuries)
- Obstetric complications (e.g., placental abruption, amniotic fluid embolism)
- Malignancies (particularly acute promyelocytic leukemia)
- Severe toxic or immunologic reactions
- Vascular disorders (e.g., large aortic aneurysms)
DIC can present as an acute, life-threatening emergency or a chronic, subtler form. The acute form is characterized by a sudden onset of bleeding and clotting abnormalities, while the chronic form may have a more gradual onset and less severe symptoms.
Nursing Process
Early recognition and prompt intervention are crucial in managing DIC. Nurses play a vital role in monitoring patients for signs of DIC, administering prescribed treatments, and providing supportive care. The primary goals of nursing care in DIC are to support hemodynamic stability, manage bleeding and clotting complications, and address the underlying cause.
A thorough assessment is essential, including frequent monitoring of vital signs, bleeding tendencies, and laboratory values such as platelet count, fibrinogen levels, and coagulation studies. Nurses must be vigilant in recognizing early signs of DIC, such as unexplained bruising, oozing from venipuncture sites, or bloody secretions.
Safety is a top priority in DIC management, as patients are at high risk for both bleeding and thrombotic complications. Nurses must implement appropriate precautions to prevent injuries and manage potential bleeding episodes effectively.
Nursing Care Plans
The following nursing care plans address the key aspects of caring for a patient with Disseminated Intravascular Coagulation. Each plan includes the nursing diagnosis statement, related factors, nursing interventions with rationales, and desired outcomes.
1. Risk for Bleeding
Nursing Diagnosis: Risk for Bleeding related to coagulation factor depletion and thrombocytopenia secondary to DIC.
Related Factors:
- Decreased platelet count
- Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT)
- Decreased fibrinogen levels
Nursing Interventions and Rationales:
- Monitor for signs of bleeding (e.g., petechiae, ecchymosis, hematemesis, melena) q2h.
Rationale: Early detection of bleeding allows for prompt intervention. - Assess all bodily secretions and excretions for the presence of blood q4h.
Rationale: Occult bleeding may be present in various body systems. - Maintain venipuncture site pressure for at least 5 minutes after blood draws or IV removal.
Rationale: Prolonged pressure helps prevent hematoma formation. - Administer blood products as prescribed (e.g., fresh frozen plasma, cryoprecipitate, platelets).
Rationale: Replaces depleted clotting factors and platelets to reduce bleeding risk. - Avoid intramuscular injections and use small-gauge needles for necessary injections.
Rationale: Minimizes tissue trauma and reduces the risk of hematoma formation.
Desired Outcomes:
- The patient will demonstrate no signs of active bleeding.
- The patient’s laboratory values (PT, aPTT, fibrinogen, platelet count) will trend towards normal ranges.
2. Ineffective Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion related to microvascular thrombosis secondary to DIC.
Related Factors:
- Widespread clot formation in small blood vessels
- Organ ischemia
- Hemodynamic instability
Nursing Interventions and Rationales:
- Monitor vital signs, including blood pressure, heart rate, and oxygen saturation q1h.
Rationale: Allows for early detection of hemodynamic instability. - Assess peripheral perfusion (e.g., capillary refill, skin color, temperature) q2h.
Rationale: Provides information about tissue oxygenation and perfusion status. - Administer oxygen therapy as prescribed and monitor oxygen saturation continuously.
Rationale: Improves tissue oxygenation and helps prevent further organ damage. - Position the patient to optimize tissue perfusion (e.g., elevate the head of the bed 30 degrees).
Rationale: Promotes venous return and reduces the risk of thrombosis. - Administer anticoagulants as prescribed (e.g., heparin) and monitor for therapeutic effect.
Rationale: Helps prevent further clot formation and improve tissue perfusion.
Desired Outcomes:
- The patient will maintain stable vital signs within normal parameters.
- The patient will demonstrate improved peripheral perfusion (e.g., warm extremities, capillary refill <3 seconds).
3. Risk for Shock
Nursing Diagnosis: Risk for Shock related to widespread microvascular thrombosis and potential severe bleeding secondary to DIC.
Related Factors:
- Hemodynamic instability
- Potential for massive blood loss
- Organ dysfunction
Nursing Interventions and Rationales:
- Monitor for signs of shock (e.g., hypotension, tachycardia, altered mental status) q1h.
Rationale: Early recognition of shock allows for prompt intervention. - Maintain two large-bore IV access sites and be prepared for rapid fluid resuscitation.
Rationale: Ensures readiness for immediate fluid or blood product administration if needed. - Administer fluid resuscitation and vasopressors as prescribed.
Rationale: Helps maintain adequate tissue perfusion and prevent organ failure. - Monitor urine output hourly and notify the physician if <0.5 mL/kg/hr.
Rationale: Oliguria may indicate inadequate renal perfusion and impending shock. - Prepare for potential interventions such as mechanical ventilation or renal replacement therapy.
Rationale: DIC can lead to multi-organ failure requiring advanced supportive measures.
Desired Outcomes:
- The patient will maintain adequate tissue perfusion, as evidenced by stable vital signs and urine output >0.5 mL/kg/hr.
- The patient will not progress to a shock state.
4. Anxiety
Nursing Diagnosis: Anxiety related to critical illness and uncertain prognosis secondary to DIC.
Related Factors:
- Life-threatening condition
- Lack of knowledge about DIC
- Fear of potential complications
Nursing Interventions and Rationales:
- Assess the patient’s level of anxiety and understanding of their condition q8h.
Rationale: Helps tailor interventions to the patient’s specific needs and concerns. - Provide clear, concise explanations about DIC, treatments, and procedures.
Rationale: Knowledge can help reduce anxiety and promote cooperation with treatment. - Encourage the patient to express concerns and ask questions.
Rationale: Allows for addressing specific worries and providing emotional support. - Maintain a calm and reassuring demeanor when interacting with the patient.
Rationale: A calm environment can help reduce anxiety and promote a sense of safety. - Offer relaxation techniques such as deep breathing or guided imagery.
Rationale: These techniques can help reduce anxiety and promote a sense of control.
Desired Outcomes:
- The patient will verbalize understanding of their condition and treatment plan.
- The patient will demonstrate reduced anxiety levels as evidenced by decreased restlessness and verbalizations of worry.
5. Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired Skin Integrity related to thrombocytopenia and potential for pressure injuries secondary to DIC.
Related Factors:
- Decreased platelet count
- Potential for prolonged immobility
- Risk of pressure injuries due to hemodynamic instability
Nursing Interventions and Rationales:
- Perform a comprehensive skin assessment q4h, paying special attention to bony prominences.
Rationale: Early detection of skin breakdown allows for prompt intervention. - Implement a turning schedule, repositioning the patient at least every 2 hours.
Rationale: Regular repositioning helps prevent pressure injuries. - Use pressure-redistributing devices (air mattress, heel protectors) as appropriate.
Rationale: These devices help reduce pressure on vulnerable areas. - Minimize friction and shear during patient repositioning by using draw sheets.
Rationale: Reduces the risk of skin tears in patients with fragile skin due to thrombocytopenia. - Keep skin clean and dry by using pH-balanced cleansers and moisturizers.
Rationale: Proper skin care helps maintain skin integrity and prevent breakdown.
Desired Outcomes:
- The patient’s skin will remain intact without evidence of breakdown or pressure injuries.
- The patient will not develop new bruises or ecchymoses related to repositioning or care activities.
Conclusion
Managing a patient with Disseminated Intravascular Coagulation requires vigilant monitoring, prompt interventions, and comprehensive nursing care.
Nurses can significantly impact patient outcomes by addressing the key aspects of bleeding risk, tissue perfusion, potential for shock, anxiety, and skin integrity.
Early recognition of DIC signs and symptoms and appropriate nursing interventions can help prevent complications and support the patient through this critical illness.
References
- Boral, B. M., Williams, D. J., & Boral, L. I. (2016). Disseminated Intravascular Coagulation. American Journal of Clinical Pathology, 146(6), 670-680. https://doi.org/10.1093/ajcp/aqw195
- Levi, M., & Scully, M. (2018). How I treat disseminated intravascular coagulation. Blood, 131(8), 845-854. https://doi.org/10.1182/blood-2017-10-804096
- Wada, H., Thachil, J., Di Nisio, M., Mathew, P., Kurosawa, S., Gando, S., Kim, H. K., Nielsen, J. D., Dempfle, C. E., Levi, M., & Toh, C. H. (2013). Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. Journal of Thrombosis and Haemostasis, 11(4), 761-767. https://doi.org/10.1111/jth.12155
- Butenas, S., & Mann, K. G. (2017). Mechanism of disseminated intravascular coagulation. Critical Care Clinics, 33(2), 203-218.
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (15th ed.). F.A. Davis Company.
