DIC

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DIC

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Coagulopathy

a.k.a. a clotting disorder or bleeding disorder Impaired coagulation hemorrhage e.g.

Hemophilia Thrombocytopenia Heparin overdose DIC

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DIC - definition

Disseminated intravascular coagulopathy is a bleeding disorder characterized by:

1. inappropriate clotting trigger = the underlying disease

2. widespread clotting = thrombosis3. exhaustion of normal clotting mechanisms4. uncontrolled bleeding = hemorrhage

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DIC - etiology

Inappropriate triggers Cancer* Envenomation Infection Liver disease* Pregnancy Rejection Shock SLE * Trauma

DIC is a syndrome, not the disease Must identify underlying disease

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DIC - pathophysiology

How it should work Coagulation

Local damage to endothelium Platelets bind to exposed

collagen Release of Tissue Factor Clotting factor cascade fibrin

Fibrinolysis Plasmin cleaves fibrin Fibrin degradation products

(FDPs) released e.g., d-dimer

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DIC - pathophysiology

What happens instead Coagulation

Inappropriate trigger Tissue Factor released in excess Widespread clotting Widespread ischemia, necrosis

Fibrinolysis More clots means more clot

busting Excess of FDPs released

anticoagulant

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DIC - pathophysiology

Clotting mechanism exhausted Platelets consumed faster than replaced Clotting factors consumed faster than replaced Inability to form new clots when needed

r/f hemorrhage

Clinical Manifestations

S/S of DIC depend on cause, and whether condition is acute or chronic

Acute DIC: clotting usually occurs first, followed by bleeding. But bleeding is often the first obvious sign. With acute blood loss, emergency care is needed.

Blood clotting occurs with chronic DIC, and doesn’t always lead to bleeding. The condition lasts longer and may have no signs, so it wont be recognized as quickly as acute DIC

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DIC - Clinical manifestations - Clotting

Systemic clotting throughout the body’s small blood vessels.

Respiratory: tachypnea, dyspnea, SOB, S/S of PE and ARDS

Cardio: chest pain, EKG changes, S/S MI GI: abdominal pain, paralytic ileus GU: kidney damage, oliguria, ARF DVT: pain, redness, warmth, edema CVA: headaches, speech changes, paralysis Skin: cyanosis, ischemic tissue necrosis

DIC - Clinical manifestations - Bleeding

Internal bleeding can occur in any organ and the bleeding can be life threatening

Respiratory: tachypnea, hemoptysis, orthopnea Neuro: vision changes, dizziness, headache,

change in mental status Cardio: hypotension, tachycardia GU: hematuria GI: frank/occult stool, upper and lower GI bleed Skin: purpura, petechiae, pallor, oozing,

hematomas, bruising, prolonged bleeding from minor cuts

Epistaxis, bleeding gums, heavy menstrual bleed

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Diagnostic Testing

CBC with blood smear APTT PT/INR Serum fibrinogen: Fibrinogen is a protein that helps

the blood clot. Fibrin degradation products (fibrin split products):

Product left behind when clots dissolve D-dimer: a polymer from the breakdown of fibrin Factor assays: for factors V,VII,VIII,X,XIII

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Nursing Assessments

Petechiae, purpura, hematomas

IV sites, wound sites, drains GI and GU bleeding Hemoptysis Mentation Vital Signs (hypotension,

tachycardia) Pain

Nursing Interventions

Monitor PT/INR Bleeding precautions Injury prevention Turn and Position q2hours to prevent pressure Administer Heparin to inhibit coagulation Decrease anxiety

Nursing Diagnoses

Ineffective peripheral tissue perfusion Acute Pain Decreased Cardiac Output Anxiety Risk for Injury

Collaborative Care

Bleeding Chronic DIC with no active bleeding-Treat

underlying cause DIC with bleeding-Supportive treatment for

symptom management and blood transfusion therapy and treatment of underlying cause/disease

Thrombosis Heparin or Lovenox

What does the Evidence show? Transfusion therapy should be reserved for

patients with life threatening hemorrhage only Patients with DIC have activated coagulation

and blood transfusions pose major risks. Early identification can reduce complications Treatment of underlying disease must occur Manage inflammatory-immune response Stabilize patient and achieve hemostasis Inflammation activates coagulation so all

patients with injury, sepsis, trauma or systemic inflammation have altered coagulation and require careful and close monitoring

(Dressler, 2012)

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DIC Summary slide

1. DIC includes 2 life-threatening conditions:

widespread clotting uncontrollable hemorrhage***

2. Clinical s/s include both clotting and bleeding. Be aware of the changes that occur in both situations

T/F: DIC is a life-threatening disease.

A. TrueB. False

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T/F: The primary threat with DIC is widespread clotting throughout the body.

A. TrueB. False

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0%0%

An RN is assessing a pt being tested for DIC. Which symptom would not be noted?

A. HTNB. OliguriaC. SOBD. Paralytic ileus

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HTN

Oliguria SOB

Paralyti

c ileus

0% 0%0%0%

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Q&A

Anything needing further explanation?

Feelings to be shared?

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References

Frazier, T. (2012) Disseminated intravascular coagulation and implications for

medical-surgical nurses. Med-Surg Matters, 21(3/4), 8-11.

Hinds, M. H., Hyland, J. R., Lovric, A., Nibert, Ainslie, & Upchurch, S. (2011).

HESI comprehensive review for the NCLEX-RN examination (3rd ed.). St.

Louis, MOElsevier.

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M.

(2011). Medical-surgical nursing: Assessment and management of clinical

problems. Saint Louis, MO: Elsevier Mosby.

NIH/MedlinePlus. (2014, February 5). Disseminated Intravascular Coagulation

(DIC). Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/000573.htm