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

Nurse Keisha works in the intensive care unit and is caring for Sharon, a 63-year-old patient who was diagnosed with disseminated intravascular coagulation, or DIC. Nurse Keisha 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 Keisha recognizes important cues, including Sharon’s vital signs which are temperature 99.8° F, or 38.7° C, heart rate 112 beats per minute, respirations 18 breaths per minute, blood pressure 112/64 mmHg, and oxygen saturation 98 percent on 2 liters of oxygen by nasal cannula.

Sharon is alert and oriented.

In her fingertips, she reports chills and aching.

Upon assessment, Nurse Keisha 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 Keisha analyzes these cues. She reviews the electronic health record, or EHR, 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 9,000/mm3; her activated partial thromboplastin time, or aPTT, and prothrombin time, or PT, are elevated, indicating coagulopathy, or impaired clotting.

In addition, D-dimer 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 Keisha knows DIC is a life-threatening 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 aPTT and PT rise;

fragments from clot breakdown are evident; fibrinogen levels decrease; and the patient begins to experience ecchymosis and bleeding.

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

Nurse Keisha recognizes that Sharon needs prompt management of her DIC.