Critical care case study - Disseminated intravascular coagulation (DIC): Nursing

Nurse, Kisha works in the intensive care unit and is caring for Sharon. A 63 year old patient who was diagnosed with disseminated intravascular coagulation or D IC.

Nurse Kesha goes through the steps of the clinical judgment measurement model to make clinical decisions about Sharon's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Kesha recognizes important cues including Sharon's vital signs which are temperature 99.8 °F or 38.7 °C. Heart rate 112 BPM respirations, 18 breaths per minute BP, 1 12/64 millimeters of mercury and oxygen saturation.

98% on 2 L of oxygen by nasal cannula. Sharon is alert and oriented in her fingertips.

She reports chills and aching upon assessment. Nurse Kia notices scattered areas of ecchymosis on Sharon's arms bilaterally as well.

There's a small amount of blood oozing from Sharon's venipuncture site and her gums. Next.

Nurse Kisha analyzes these cues. She reviews the electronic health record or E hr and notes that Sharon has been receiving treatment for bacterial pneumonia and has peripheral blood cultures pending for suspected sepsis.

Her most recent laboratory results show a platelet count of 9000 cubic millimeters. Her activated partial thromboplastin time or a PTT and prothrombin time or PT are elevated indicating coagulopathy or impaired clotting.

In addition, ddimer and fibrin degradation products, which are protein fragments made when clots are dissolved, are elevated and fibrinogen.

A protein needed for clot formation is decreased. Nurse Kia knows D IC is a lifethreatening complication that can be triggered by many different conditions including sepsis.

In this situation, the systemic inflammatory response to the infection causes an excessive activation of coagulation pathways and suppression of fibrinolysis.

Meaning there's uncontrolled clotting along with an impaired clot breakdown. This leads to widespread microvascular thrombosis which involves formation of blood clots in the small blood vessels.

These clots block circulation causing cyanosis in places like the fingers, toes, ears and nose and can even progress to gangrene as the coagulation factors are used up.

The platelet count drops both the A PTT and PT rise fragments from clot breakdown are evident. Fibrinogen levels decrease and the patient begins to experience ecchymosis and bleeding.

Eventually D I can lead to organ ischemia and dysfunction like respiratory failure, acute kidney injury and bowel infarction.

Nurse Kisha recognizes that Sharon needs prompt management of her D IC. Now using the information she's gathered.

Nurse Kisha chooses a priority hypothesis of risk for hemorrhage. Then she generates solutions to address Sharon's risk for hemorrhage including pharmacologic and nonpharmacologic interventions.

And she establishes the expected outcome that one hour after intervening Sharon's laboratory values will demonstrate a decreased risk of bleeding and there will be no signs of active bleeding.

Then nurse Kesha takes action to implement these solutions. She speaks with the critical care provider to report her assessment findings and obtains orders to transfuse one unit of platelets and start a broad spectrum intravenous antibiotic.

After gathering the necessary supplies, nurse Kisha reentered Sharon's room. Hi, Sharon.

I just spoke with the provider who put in some orders to help reduce your risk of bleeding. Ok.

Seeing all these bruises is really making me anxious. I understand I'm going to start a transfusion of platelets which will help your body slow the bleeding and prevent new bruises from forming.

Then I'll administer an IV antibiotic to help treat your infection. After Sharon communicates and understanding of the plan of care.

Nurse Kisha collects a set of baseline vital signs before beginning the platelet transfusion. Then she administers the antibiotic following the principles of safe medication administration.

She assists Sharon into a comfortable position, supports her limbs with pillows and ensures the bed rails are in the upright position to prevent Sharon from falling.

She institutes bleeding precautions including avoiding unnecessary venipunctures, providing a soft bristled toothbrush, initiating fall precautions, checking for signs of bleeding frequently and using signs above Sharon's bed and outside of her door, alerting the care team to the bleeding precaution before leaving the room nurse, Keisha ensures the vital sign monitor is programmed appropriately.

Then she hands Sharon the call light and tells her she will be monitoring her vitals and the platelet infusion closely. One hour after the platelet transfusion is complete.

Nurse Kisha evaluates the outcomes of her actions. She takes Sharon's vital signs which are temperature 99.5 °F or 37.5 °C.

Heart rate 102 BPM, respirations, 16 breaths per minute BP. 1 22/78 millimeters of mercury and oxygen saturation.

99% on 2 L by nasal cannula. Upon assessment, there are no indications of new bleeding and the bleeding from Sharon's gums and venipuncture site has stopped.

Additionally, Sharon's post transfusion platelet count is 15,000 cubic millimeters. All right.

As a quick recap. Nurse Kia recognized and analyzed cues related to Sharon's increased risk of hemorrhage due to D IC and prioritized hypotheses and generated solutions to address this problem.

Nurse Kecia then took action implementing pharmacologic and non pharmacologic measures to manage Sharon's D IC and evaluated the outcomes compared with the expected outcomes since Sharon's laboratory values improved and there was no evidence of active bleeding.

One hour after the interventions, nurse Kia determined that the plan of care was successful