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DIC

Stephanie, Emily, Kevin

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

A.TrueB.False

2

TrueFa

lse

0%0%

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

A.TrueB.False

3

TrueFa

lse

0%0%

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

A.HTNB.OliguriaC.SOBD.Paralytic ileus

4

HTN

Oliguria SOB

Paralyti

c ileus

0% 0%0%0%

:15

All of the following statements regarding DIC are true except. ?

A. The rapidity and intensity of onset is triggered by condition of patients liver, endothelium and bone marrow.

B. The early phase may include symptoms of thrombosis.

C. Excessive blood loss rarely results in shockD. Early identification is the most critical

intervention

5

:15

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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

disease2. 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 14

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 slide1. 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

3. Identify and treat the underlying condition Supportive care for human needs related to

bleeding (Transfusion for critical cases only) Anticoagulants for Thrombosis DIC.

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

A. TrueB. False

22True

False

0%0%

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

A. TrueB. False

23True

False

0%0%

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

A. HTNB. OliguriaC. SOBD. Paralytic ileus

24HTN

Oliguria SOB

Paralyti

c ileus

0% 0%0%0%

:15

Something about DIC collaborative care?

25HTN

Oliguria SOB

Paralyti

c ileus

0% 0%0%0%

:15

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Q&A

Anything needing further explanation?

Feelings to be shared?

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References Dressler, D. (2012). Coagulopathy in the intensive care unit. Critical Care Nurse,

32 (5). 48-60.

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, MO:

Elsevier.

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