Page 441 - Critical Care Nursing Demystified

426 CRITICAL CARE NURSING DeMYSTIFIED

Find and treat the underlying cause.
Continuous IV heparin is used in severe cases of DIC.

Administration of antifibrinolytic agents like aminocaproic acid (Amicar).
Drotrecogin alfa administration.
Blood component replacement with fresh frozen plasma or cryoprecipitate.
Administration of vitamin K and folate.

6 Nursing Diagnoses for DIC Expected Outcomes
Tissue perfusion, alteration due to The patient will maintain all peripheral
clotting in microcirculation pulses
Increased fluid volume deficit due to The patientʼs Hct, Hgb, and platelets
bleeding will stabilize

Nursing Interventions
1. Assess vital signs frequently for signs of hemorrhagic shock (elevated HR,
breathing, and decreased BP) to identify and treat shock from DIC early.
2. Administer oxygen to decrease tissue hypoxia. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

3. Prepare to insert a pulmonary artery catheter to measure volume replace-
ment and ability of heart to handle fluids. Notify the physician if PAOP and
CO readings drop, which can indicate shock.
4. Prepare to administer blood products to replace volume and clotting factors.

5. Avoid the use of rectal temps and suppositories, which can cause bleeding
of intestinal mucosa.

6. Monitor the skin under noninvasive sequential BP devices frequently.
7. Monitor all invasive sites for bleeding (nasogastric tubes, urinary catheters,
ETT) as they can be potential sites for increased blood loss/hemorrhage.
8. Hold all invasive venous procedure sites for 15 minutes to allow hemo-
stasis to occur.
9. Use gentle-tipped applicators for oral care. Do not include harsh alcohol-
based mouth wash. Prevents trauma and potential bleeding of the gingiva.
10. Use electric razors for grooming to prevent nicks, which can bleed excessively.
11. Do not disturb clots that form such as in the oral cavity, which can reac-
tivate mucous membrane bleeding.
12. Trend all hemodynamic and body system assessments for signs of further
tissue hypoxemia and bleeding.