DISSEMINATED

INTRAVASCULAR
COAGULATION
 OBJECTIVES
At the end of this study, the reader should be able to
accomplish the following:
• Define (DIC) Disseminated Intravascular
Coagulation and identify its probable risk factors.
• Understand the disease/condition’s process and
trace a simple pathophysiology it presents.
• Distinguish and rationalize the nursing
implementations needed for this study,
incorporating the Nursing Process.
• Know and comprehend the rationale behind
managements rendered and the certain actions
of medications administered/ prescribed.
 BRIEF DESCRIPTION

• Disseminated intravascular coagulation

(DIC) is a life-threatening hemostatic
disarray in which bleeding and clotting
occur simultaneously.
• It is also called CONSUMPTIVE
COAGULOPATHY or
• DEFIBRINATION SYNDROME.
 REMINDER!

• DIC is not itself a specific illness; rather,

it is a complication or an effect of the
progression of other illnesses. It is
always secondary to an underlying
disorder and is associated with a
number of clinical conditions, generally
involving activation of systemic
inflammation.
• DIC exists in both Acute and Chronic forms.
• Acute DIC develops when sudden
exposure of blood to procoagulants
generates intravascular coagulation.
• Chronic DIC reflects a compensated state
that develops when blood is continuously
or intermittently exposed to small amounts
of Tissue Factor. Chronic DIC is more
frequently observed in patients with solid
tumors and in large aortic aneurysms.
 PREVALENCE & STATISTICS

• DIC has no known prevalence in gender.

Both male and female stand an equal
chance of developing the condition. It is also
known to affect people of all ages regardless
of the geographical location. Regarding its
connection with genetic factors, it also has
no known genetic influence. Normally, the
mortality rate depends on the underlying
disorder but the condition worsens the
prognosis of all disorders.
 PREVALENCE & STATISTICS
• Disseminated Intravascular Coagulation occurs at higher
rates in people with bacterial sepsis (83%), severe
trauma (31%), and cancer (6.8%), and it develops in an
estimated 1% of all hospitalized patients.
Based on the Underlying Condition/s
1%
6% Bacterial Sepsis

25% Severe Trauma

Cancer
68%
the rest of the
Hospialized Patients
ANATOMY & PHYSIOLOGY
 RISK & ETIOLOGIC FACTORS
• Multiple medical conditions can lead to the
development of disseminated intravascular
coagulation either through a systemic
inflammatory response or the release of
procoagulants into the bloodstream. The
pathological process of DIC has been linked to
cases:
severe sepsis, which is the
most common cause of DIC
Patients with metastasized
adenocarcinoma or lymphoproliferative
 MORE RISK & ETIOLOGIC FACTORS
Patients with chronic diseases like solid
tumors and aortic aneurysms
 Obstetrical complications such as
placental abruption, hemolysis, elevated
liver enzymes, and low platelet count (HELLP
syndrome), and amniotic fluid embolism
 Other causes of DIC include trauma,
pancreatitis, malignancy, snake bites, liver
disease, transplant rejection, and transfusion
reactions
PATHOPHYSIOLOGY
 ASSESSMENT
• With Acute DIC, the physical findings are
usually those of the underlying or inciting
condition; however, patients with the acute
disease have petechiae on the soft palate,
trunk, and extremities from
thrombocytopenia and ecchymosis at
venipuncture sites and in traumatized areas.
 ASSESSMENT
In patients with so-called chronic or
subacute DIC, of which the primary
manifestation is thrombosis from
excess thrombin formation, the signs
of venous thromboembolism may be
present.
 ASSESSMENT

Circulatory signs
include the following: Genitourinary signs
• Signs of spontaneous include the following:
and life-threatening • Signs of azotemia and
hemorrhage renal failure
• Signs of subacute • Acidosis
bleeding/ bleeding in • Hematuria
serous cavities • Oliguria
• Signs of diffuse or • Metrorrhagia
localized thrombosis • Uterine hemorrhage
 ASSESSMENT

Central nervous system signs Respiratory signs include

include the following: the following:
• Nonspecific altered • Pleural friction rub
consciousness or stupor • Signs of acute respiratory
• Transient focal neurologic distress syndrome (ARDS)
deficits
Gastrointestinal signs
Cardiovascular signs include include the following:
the following: • Hematemesis
• Hypotension • Hematochezia
• Tachycardia
• Circulatory Collapse
 ASSESSMENT
Dermatologic signs include the following:
• Petechiae
• Jaundice (liver dysfunction or hemolysis)
• Skin necrosis of lower limbs (purpura fulminans)
• Localized infarction and gangrene
• Wound bleeding and deep subcutaneous
hematomas
• Thrombosis
• Purpura
• Hemorrhagic bullae
• Acral cyanosis
DIAGNOSTIC FINDINGS
 DIAGNOSTIC FINDINGS
Standard tests:
In clinical practice, a diagnosis of
DIC can often be made by a
combination of the following
tests:
• Platelet count
• Global clotting times (aPTT
and PT)
• One or two clotting factors and
inhibitors (eg, antithrombin)
• Assay for D-dimer or Fibrin
Degradation Products (tests the
Fibrinolysis)
 MANAGEMENT
• Pharmacologic Therapy
Treatment of disseminated intravascular
coagulation (DIC) is controversial, but
treatment guidelines have been published
eversince.
 MANAGEMENT
Drug Drug Action
Heparin Inhibits the formation of
microthrombi and thus
permit perfusion of the
organs to resume.
Exerts direct effect
on blood coagulation by
enhancing the inhibitory a
ction of antithrombin III on
several factors essential to
normal blood clotting,
thereby blocking the
conversion of prothrombin
to thrombin and
fibrinogen to fibrin.
Nursing Responsibilities
Monitor vitals, report
fever, drop in BP, rapid
pulse and other S/Sx of
hemorrhage.
Observe all needle sites
daily for hematoma
and signs of
inflammation.
Have on hand
protamine sulfate,
specific heparin
antagonist
Drug Drug Action Nursing Responsibilities
Anti- Inactivates thrombin Reconstitute, administer, and
thrombin III and increases handle the administration set and
effects of Heparin. needle cautiously.
Serine protease Place needles in a sharps
inhibitor; important container, and discard all
natural inhibitor of equipment including any unused
blood coagulation; product in an appropriate
inactivation of container. Human antithrombin III
thrombin, plasmin, (is made from human plasma and
and other active may contain infectious agents.
serine proteases of Visually inspect parenteral
coagulation products for particulate matter
including factors IXa, and discoloration prior to
Xa, XIa, and XIIa. administration whenever solution
and container permit.
Once reconstituted, human
antithrombin III should be given
alone, without mixing with other
agents or diluting solutions.
 MANAGEMENT
Drug Drug Action Nursing Responsibilities
Drotrecogin Diminishes Should clinically
alfa- inflammatory important bleeding
activated responses on the occur, stop the infusion.
(Xigris) surface of the Discontinue 2hours prior
vessels as well as to undergoing an
having invasive surgical
anticoagulant procedure or procedures
properties with a risk for bleeding.
Assess status of
coagulopathy.
Protect from any source
of light.
 MANAGEMENT
Surgical
DIC can result from
numerous clinical
conditions, including
sepsis, trauma, obstetric
emergencies, and
malignancy.
On that note, the Surgical
management is limited to
primary treatment of
certain underlying
disorders.
 PREVENTION
• The preventive measures for the condition can be
categorized into two broad categories namely:
the primary prevention methods and the secondary
prevention methods:
The main aim of primary prevention focuses on
either the early treatment of the condition or the
treatment of underlying conditions responsible for
precipitating DIC.
Secondary prevention involves active and
effective treatment of the condition to repair the
deranged coagulation system.
 (NCP) NURSING PROCESS
• Problem: Bleeding
• NDx: Fluid Volume Deficit related to Hemorrhage
• NOC: Fluid Balance
• Goal/s: (Short and Long Term)
> After 1 hour of Nursing Intervention, client will verbalize
understanding and purpose of therapeutic
interventions. He/ she will be able to demonstrate
behaviors to monitor and correct deficit, as
appropriate.
> After 8 hours of Nursing Intervention, client will be able
to maintain fluid volume at a functional level as
evidenced by individually adequate urinary output
with normal specific gravity, stable vital signs, moist
mucous membranes, good skin turgor, prompt
capillary refill, abscence bleeding.
NIC: Hypovolemia Management
1. Monitor vital signs closely, including
neurologic checks:
a. Monitor hemodynamics.
b. Monitor abdominal girth.
c. Monitor urine output.
Identifies signs of hemorrhage/ shock quickly.
2. Avoid procedures/activities that can increase
intracranial pressure (eg, coughing, straining to
have a bowel movement). Prevents intracranial
bleeding.
3. Avoid medications that interfere with platelet
function if possible (eg, ASA, NSAIDs, beta-lactam
antibiotics). Decreases problems with platelet
aggregation and adhesion.
4. Avoid rectal probes, rectal medications and
Intramuscular injections. Decreases chance of
bleeding.
5. Monitor amount of external bleeding
carefully.
a. Monitor number of dressings, % of dressing
saturated; time to saturate a dressing is more
objective than “dressing saturated a
moderate amount.” Provides accurate,
objective assessment of extent of bleeding.
b. Assess suction output, all excreta for frank or
occult blood. Identifies presence of or
quantifies extent of bleeding.
c. Monitor pad counts in women with vaginal
bleeding. Quantifies extent of bleeding.
d. Females may receive progesterone to prevent
menses. Decreases chance for gynecologic
source of hemorrhage.)
6. Use low pressure with any suctioning needed.
Prevents excessive trauma that could cause
bleeding.
7. Administer oral hygiene carefully.
a. Avoid lemon-glycerine swabs, hydrogen peroxide,
commercial mouthwashes.
b. Use sponge-tipped swabs, salt/baking soda
(bicarbonate of soda) mouth rinses. Prevents
excessive trauma that could cause bleeding.
Glycerin and alcohol (in commercial
mouthwashes) will dry mucosa, increasing risk for
bleeding.
8. Avoid dislodging any clots, including
thosearound IV sites and injection sites.
Prevents excessive bleeding at sites.
9. Evaluate client’s ability to manage own
hydration. Impaired gag and swallow
reflexes, anorexia, nausea, oral
discomfort and changes in level of
consciousness (LOC) are among the
factors that affect client’s ability to
replace fluids orally.
10.Monitor laboratory studies, as indicated.
Depending on the avenue of fluid loss,
differing electrolyte and metabolic
imbalances may be present and require
correction.
11.Prepare a Fresh Whole blood or packed
RBC transfusion and autologous
collection of blood as ordered. Indicated
when hypovolemia is related to active
blood loss
• Evaluation: (Goal Met)
> After an hour of Nursing Intervention, the
client verbalized understanding and
purpose of therapeutic interventions. He
was able to demonstrate behaviors to
monitor and correct deficit, as appropriate
and as tolerated.
> After 8 hours of Nursing Intervention, client
was able to maintain fluid volume at a
functional level as evidenced by individually
adequate urinary output with normal
specific gravity, stable vital signs, moist
mucous membranes, good skin turgor,
prompt capillary refill and absence of
bleeding.
 4 PROBLEMS & NDX
• Shortness of Breath: Ineffective Tissue Perfusion
related to bleeding and sluggish or diminished
blood flow secondary to thrombosis
• (Petechia) Skin Rash: Impaired Tissue Integrity
related to Altered Circulation
• Anxiety: Anxiety related to Fear of the Unknown,
disease process
• Edema: Risk for fluid Volume excess related to
Ischemia affecting
Major Organs (Kidney)