04.06 Disseminated Intravascular Coagulation (DIC)

Overview

  1. A very serious condition that is caused by an issue with the clotting cascade
    1. Occurs in postpartum patients due to activation of the clotting cascade after birth/separation of placenta
  2. Please view full explanation of DIC in our Hematology/Oncology/Immunology course

Nursing Points

General

  1. Clots form rapidly and extensively, completely depleting clotting factors
  2. Severe hemorrhage results (eyes, ears, nares, rectum, and so forth)
  3. Patients bleed from all orifices and various vascular occlusion of organs also result

Assessment

  1. Presents like sepsis / shock
  2. Lots of bleeding from literally everywhere
  3. Microclots – petechiae, purpura
  4. Labs
    1. Decreased:  Hematocrit, fibrinogen, platelets
    2. Increased:  PT, PTT, clotting time, fibrin degradation products (FDPs)

Therapeutic Management

  1. Draw labs (CBC, coagulation studies, metabolic panels)
  2. Watch for bleeding
  3. Support hemodynamics
  4. Administer fluid replacements, blood products, and heparin as ordered
    1. Monitor for complications with administering them
  5. Monitor for kidney failure
  6. Possibly prepare patient for hysterectomy

Nursing Concepts

  1. Clotting
  2. Perfusion

Patient Education

  1. Education on what is happening
  2. Symptoms to report for hysterectomy or blood transfusion if they occur

Reference Links

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Video Transcript

In this lesson I will explain the key points of disseminated intravascular coagulation and your role for this patient

The big picture idea to understand is disseminated intravascular coagulation also known as DIC occurs when there is an overreaction of the clotting system. The patient clots and bleeds, clots and bleeds. It can cause intravascular thrombin and fibrin, resulting in the thrombosis of vessels. The end result will be organ dysfunction because of these clots and severe bleeding. bleeding.

This is a very serious condition that is caused by an issue with the clotting cascade. This occurs in our postpartum patients because the placenta is detached which is an open wound so the clotting cascade is activated. Many clots form quickly which will deplete the clotting factors. Now we have no clotting factors so we have severe hemorrhage. A hallmark symptom is bleeding out of any orifice so bleeding from eyes, ears, nares, rectum, and even IV sites.
The patient’s labs will have decreased hematocrit, fibrinogen, and platelets. Hematocrit is low because of the bleeding. Fibrinogen and platelets are low because we are using it up for clotting and there is platelet aggregation occurring. PT, PTT, clotting time, and fibrin degradation products (FDPs) have all increased. Clotting time increases because the body has used up all the clotting factors so now it takes longer and longer to form a clot. Fibrin degradation products are increased because clots are quickly being broken down Now with this understanding let’s look at the symtoms. We have bleeding because we have used up our clots and the body can not keep up. There is petechiae because of micro clots forming which causes the tiny vessels to break open so bleeding occurs under the skin which will cause purpura. Sepsis is sometimes a cause of DIC so the patient might show symptoms of this and quickly turn to DIC. Shock symptoms occur because of all the bleeding so things like tachycardia, clammy, and paleness.
Now if you have a patient with DIC you need to know how to provide care. Lab work needs to be drawn. This will include CBC, coagulation studies, and metabolic panels. The CBC is going to show us the hematocrit and hemoglobin. Coagulation studies will help us to understand all the different coagulation pieces and where the number stands. Metabolic panels will help us to keep an eye on organ function. With DIC organ failure occurs because of the microclots that cause thrombosis in the vessels. We need to be watchful of bleeding and ensure the patient isn’t bleeding too heavily at any point. We need to support the hemodynamic system so transfusing blood and or platelets might be essential to their care. Fluids or heparin might also be needed to help with replacement and for clotting. We want to stop the clotting cascade because then we will stop using ll the clotting factors. So heparin will stop the cascade and stop the use of the clotting factors so that patient will again have enough to clot on their own. There is a lesson in the hematology section on DIC that helps explain this if you need more detail. We also might need to prepare the patient for surgery to remove the uterus to help stop the overreaction of the clotting system.
Education is going to revolve around explaining what is happening to the patient. This is an emergency so as a nurse you are acting fast but explanation should occur when it can. Explaining that her bleeding is heavy and that we are going to be watching closely is a good way to explain to the patient as to why she is being cared for so closely and help reassure her that you are keeping an eye on everything. If lab work is being done then explanation can revolve around what you are checking with the labs. If the patient has a hysterectomy then she needs education on how the procedure will happen and signs to report. She will likely need blood products so she should know symptoms to report of a transfusion reaction.

Clotting and perfusion are the nursing concepts for a patient with DIC because we have an over activation of the clotting system and this is going to cause perfusion problems to the organs.
There are a few key points to focus on. Disseminated intravascular coagulation is an emergency so we need to act fast! There is an overreaction of the clotting cascade so the body will continuous bleed and clot. Remember this will cause tiny clots and thrombosis in the vessels that could lead to organ failure. The main symptom is a continuous bleeding and bleeding out of open orifices. If there is a hole there is bleeding from it. Hematocrit, platelets and fibrinogen will all be decreased because of all the clotting and bleeding. Clotting time, PT, and PTT are increased because the body is trying to clot quickly. Fibrinogen degradation products are increased because there is lysis of the clots. Remember bleed clot bleed clot bleed clot. Eventually the body can not keep up.

Make sure you check out the resources attached to this lesson. Please view full explanation of DIC in our Hematology/Oncology/Immunology course

Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 6

Your 32 year old patient is 32 weeks pregnant with her first child. She was admitted for sepsis, but now the MD believes she has disseminating intravascular coagulation. Which of the following lab values would you NOT expect to see with this patient?

  • Question 2 of 6

A nurse is caring for a client that delivered a fetal demise 3 hours ago is bleeding heavily. The providers believe she has disseminated intravascular coagulation and has ordered labs to be drawn. What results would the nurse expect to see if DIC is occurring? Select all that apply.

  • Question 3 of 6

A nurse is assessing multiple postpartum clients for the risk of Disseminated Intravascular Coagulation. Which client is at the highest risk?

  • Question 4 of 6

After shift change, a nurse takes over care for a postpartum client who had been bleeding moderately and is staying on the labor unit for closer watching. What assessment finding should the nurse be the most concerned about?

  • Question 5 of 6

A nurse is caring for a postpartum client with disseminated intravascular coagulation. The client’s family wants to understand what this means. What is the best response by the nurse?

  • Question 6 of 6

A nurse is assessing a postpartum client for possible Disseminated Intravascular Coagulation. Which symptoms would the nurse expect to find?

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