Disseminated Intravascular Coagulation (DIC)

Joanne Thompson, a 38-year-old woman presented to the ER with a ruptured

appendix. She was immediately taken to the OR for an emergency appendectomy.
During her hospital stay, she developed peritonitis and was discharged 9 days later
with a left peripherally inserted central catheter (PICC) line to home care for IV
antibiotic therapy. You work for the home health agency and have assigned to
Joannes case. During your initial visit, you perform a thorough assessment of Ms.
Thomson and her home environment. During you assessment, you notice a large
ecchymotic area over the right upper arm. When you question her about it, she
responds that she had her BP taken so many times in the past week, that this left
her with bruises.
1. What do you think of this explanation? It is possible. Bruising occurs when blood
vessels (capillaries) break under the skin. She just had surgery (trauma) in which
anticoagulants may have been given as prophylaxis and subsequent bleeding may
have occurred. Also, when coagulation factors are depleted, bleeding may be
observed (in this case, ecchymoses can occur by just having pressure placed on
your arm such as a BP cuff). Concern right now would be coagulopathy.

In examining her further, you find a fine, nonraised, dark red rash over her trunk.
She reports that she didnt even notice this before you pointed it out. The rash does
not itch or cause pain. She has never had one like this before.
2. What additional information do you want at this point? Are you on blood thinners?
Do you take aspirin? Have you had any unusual bleeding, bruising, bleeding when
you brush your teeth? Is there a history of bleeding disorders? Have you
experienced any other trauma that you can recall, such as bumping your arm, knee,
etc? Get past history, baseline vitals (for norms). Recall the last BM and if there
were any abnormalities and maybe urination and if any blood present? (Trying to
find the cause)

You assess her surgical wound which is not discolored or draining. The abdomen is
tender to palpation. You notice there is serosanguinous fluid around the PICC
insertion site. The rash does not appear anywhere else on her body. You decide to
call the physician to relay this information.
3. What information are you going to relay?
Patients recent surgery, location of PICC, therapy pt is on such as antibiotics, my
assessment findings: vitals, location of the rash on the trunk and characteristics,
bruising (ecchymoses) on arm, and the PICC site complications of serosanguinous

fluid being present. Assessment of abdomen being tender to palpation and

presence/absence of bowel sounds.

The physician orders blood to be drawn for Coagulation studies and a CBC with
differential. He wants to evaluate her for DIC.
4. What lab tests would you expect to see in the coagulation studies? PT, aPTT, Ddimer, FDP, platelets, fibrinogen, BUN & creatinine

You give Ms. Thomson her antibiotic, draw her blood, and take it to the lab. You
return to her home 6 hours later to administer another dose of antibiotic. When she
greets you at the door, she is very upset and brings you to the bathroom where you
find blood in the toilet. She tells you she has been urinating blood for the past 2-3
hours. She also shows you a tissue in which she has bloody-appearing sputum and
reports that she has been coughing up blood.
5. What should you do at this point? What do you think is going on? Ask how much
blood from coughing and urinating (estimate)? Did urine smell? How many times
has she urinated? When did it start? Did it have an odor? Assess head to toe
including skin for breakdown, etc. (we are looking for other places that may be
bruised and for a possible causative factor), auscultate lungs (maybe infection,
fluid, pneumothorax), pain assessment (0-10, where at? How long? Type?)
I would notify the MD at this point because my concern is that she could be
hemorrhaging (internally) or a perforation/tear. There seems to be a clotting/coag
deficiency. I could relay my assessment findings to MD and wait for instructions.

You call the physician and he instructs you to call 911 and get her to the ER
immediately. You call the ER and give report to the triage nurse.
6. Provide a report as given to the ER nurse.
My name is Jenn. I am a home health nurse RN assigned to a 38 y/o
female patient who is 9 days post-appendectomy. Current dx is
peritonitis. Left peripheral PICC. Pt is on antibiotic therapy every 6
hours, last dose was given at __:__. Pt states she has been urinating blood
for 2-3 hours and coughing up bloody sputum (EBL _____mL). PICC line is
intact; serosanguinous fluid has been observed near PICC site. Rash
(describe it) was observed on the trunk and ecchymoses (approximately
_______cm/in) noted on right upper arm.

Upon arrival to the ER, the physician wants the patient worked up for DIC.
7. Are the patients presenting S/S consistent with DIC? Why or why not? Yes, she
has ecchymoses of the arm, abdominal tenderness which may indicate a bleed or a
distention, hematuria, hemoptysisthese indicate that the patient may be
hemorrhaging. She also had bleeding near the puncture site of the PICC.

8. What risk factors does she have that are consistent with this diagnosis?
Trauma due to appendectomy, and a dx of peritonitis; invasive line is inserted
(PICC), since she is bruising there is a risk for hemorrhage and other complications.

The following labwork comes back: PT/INR, PTT, FSP, D-dimer. platelets,
clotting time, fibrinogen level. WBC 12.5, Platelet count 46.
9. What are your nursing priorities at this time?
Assessment and monitoring- identifying and eliminating the underlying cause,
control the bleeding, Assess vital signs & cardiac, neuro, and respiratory status.
Preventing MODS and organ ischemia- tissue perfusion. Monitor patient for
hypovolemic shock (ex: hypotension, tachy, decreased perfusion, decreased u/o,
change in neuro). Hemodynamic monitoring. Intubation and ventilation may be
appropriate. Minimize oxygen consumption.

10. What interventions are appropriate at this time?

Insert a large bore IV. Support BP and circulating volume with fluids (monitoring for
fluid overload). Administer inotropics, blood products. Vitals-constant monitoring.
Comfort measures and skin breakdown prevention- cluster care to minimize stress
and risk for additional trauma. Monitor for s/s of PE (due to coagulation issues),
DVT, Respiratory- lung sounds (fluid backing up). Possibly imaging studies: CXR to
look at lungs (fluid, pneumothorax), Doppler, CT

Presently, Ms. Thompson is stable and transferred to the ICU in guarded condition.