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DIC

DIC. 1. Coagulopathy. a.k.a. a clotting disorder or bleeding disorder Impaired coagulation  hemorrhage e.g. Hemophilia Thrombocytopenia Heparin overdose DIC. 2. DIC - definition. Disseminated intravascular coagulopathy is a bleeding disorder characterized by:

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DIC

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  1. DIC 1

  2. Coagulopathy • a.k.a. a clotting disorder or bleeding disorder • Impaired coagulation  hemorrhage • e.g. • Hemophilia • Thrombocytopenia • Heparin overdose • DIC 2

  3. DIC - definition • Disseminated intravascular coagulopathy is a bleeding disorder characterized by: • inappropriate clotting trigger = the underlying disease • widespread clotting = thrombosis • exhaustion of normal clotting mechanisms • uncontrolled bleeding = hemorrhage 3

  4. 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 4

  5. 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 5

  6. 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 6

  7. 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 7

  8. 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

  9. 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 9

  10. 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

  11. 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

  12. Nursing Assessments • Petechiae, purpura, hematomas • IV sites, wound sites, drains • GI and GU bleeding • Hemoptysis • Mentation • Vital Signs (hypotension, tachycardia) • Pain 12

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

  14. Nursing Diagnoses • Ineffective peripheral tissue perfusion • Acute Pain • Decreased Cardiac Output • Anxiety • Risk for Injury

  15. 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

  16. 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)

  17. DIC Summary slide • DIC includes 2 life-threatening conditions: • widespread clotting • uncontrollable hemorrhage*** • Clinical s/s include both clotting and bleeding. Be aware of the changes that occur in both situations 17

  18. T/F: DIC is a life-threatening disease. • True • False :01

  19. T/F: The primary threat with DIC is widespread clotting throughout the body. • True • False :02

  20. An RN is assessing a pt being tested for DIC. Which symptom would not be noted? • HTN • Oliguria • SOB • Paralytic ileus :15

  21. Q&A • Anything needing further explanation? • Feelings to be shared? 21

  22. 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 22

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