Critical Alterations in Perfusion PDF

Critical Alterations in Perfusion ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Pathophysiology Occurs as a result of circulato...

Critical Alterations in Perfusion ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Pathophysiology Occurs as a result of circulatory Categories of shock failure which leads to tissue Distributive shock hypoxia, cellular death and organ A result of a decreased systemic dysfunction. vascular resistance (SVR) and perfusion. Hypovolemic shock A result of loss of 25-30% of circulating blood volume. Cardiogenic shock Systemic hypoperfusion as a result of decreased cardiac output. Obstructive shock Occurs when blood flow is blocked disrupting circulation to the major arteries. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Pathophysiology: Distributive Shock Decreased SVR and Perfusion 4 Subcategories of distributive shock Septic shock Occurs as a result of the release of inflammatory cytokines which cause damage to the internal layer of blood vessels and initiates clotting mechanisms. Anaphylactic shock Occurs in response to severe hypersensitivity to an allergen (food, medication, bee sting etc.) mediated by IgE increasing vascular permeability and vasodilation and a decreased SVR.. Neurogenic shock Occurs due to autonomic dysregulation caused by a spinal cord injury above the level of T6. Toxic shock Involves infection from Staphylococcus aureus causing excessive activation of cytokines and inflammatory cells. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Pathophysiology: Hypovolemic Shock Occurs when intravascular volume is decreased by 25% to 30% resulting in poor cardiac output Hemorrhagic shock: caused by insufficient perfusion of blood and oxygen to the body tissues resulting in an imbalance oxygen supply and demand. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Pathophysiology: Cardiogenic Shock Circulatory failure and hypoperfusion caused by cardiac dysfunction leading to myocardial ischemia. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Pathophysiology: Obstructive Shock Occurs when blood flow is blocked and circulation to the major organs is disrupted. Pulmonary embolism Pulmonary hypertension Tension pneumothorax Mechanical ventilation with high PEEP Aortic dissection Pericardial tamponade Pericardial effusion Cardiac mass ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Stages Initial Stage Progressive Stage Too little oxygen in the blood to feed Oliguria organs body switches from aerobic to Altered level of consciousness anerobic metabolism Pallor, cool clammy skin Increased lactic acid Electrolyte imbalance Compensatory Stage Hypotension Aldosterone released to maintain BP Refractory Stage Vasoconstriction to shunt blood to vital Irreversible cellular and organ failure organs and Impending death Increased HR Sympathetic nervous system releases catecholamines to compensate for low oxygen. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Etiology Sepsis Anaphylactic Pancreatitis Exposure to an allergen Burns Toxic Infection Soft tissue infection Neurogenic Postsurgical infection Spinal cord trauma Obstructive Guillain-Barre injury Tension Pneumothorax Cerebral hemorrhage High levels of PEEP Hypovolemic Cardiac tamponade Hemorrhage Pulmonary Embolism Traumatic blood loss Cardiac mass Upper/lower GI Bleed Aortic dissection Ruptured aneurysm Cardiogenic Postpartum bleed Acute MI Anticoagulants Aortic dissection ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Non-hemorrhagic excessive diuresis Cardiac arrhythmia  Shock: Impact on Overall Health Life-threatening condition All body systems at risk for failure Higher mortality rate for older adults ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Phases of Shock: Clinical Presentation Initial Progressive Subtle clinical manifestations Client’s condition deteriorates Pale skin Altered level of consciousness Client reports feeling unwell or Weak pulses anxious Skin pale or ashen Compensatory Increased capillary refill time Sympathetic nervous system is Oliguria or anuria activated Refractory Tachycardia Death is imminent Tachypnea Client comatose Decreased peripheral pulses Hypotension not responsive to BP may remain stable or fluctuate vasopressors Increased capillary refill time Renal failure resulting in anuria Respiratory failure despite oxygen therapy ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Lab & Diagnostic Testing CBC ECG Electrolytes Chest X-Ray BUN CT Scan CRE PT/PTT ALT/AST Lactate Blood, Urine and Sputum Cultures Cardiac Enzymes ABGs ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Role of the Nurse Client Teaching Provide information to client and family about the routines in ICU Familiarize client’s family with the ICU environment Reinforce information regarding diagnosis, treatment and prognosis of shock. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Nursing Process (1 of 3) Recognize Cues (Assessment) Analyze Cues (Analysis) Recognize abrupt subtle changes in Analyze hemodynamics and condition assessment findings to identify client Identify trends in vital signs, mental needs status, hemodynamics, urine output, respiratory status, cardiovascular status, etc. Frequent assessments ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Nursing Process (2 of 3) Prioritize Hypotheses (Analysis) Take Actions (Implementation) Identify manifestations early for best Hemodynamic monitoring outcomes Administer IVF and blood products Subtle changes in baseline will drive Administer and titrate IV medications prioritization of care Administer Medications Generate Solutions (Planning) Administer enteral or parenteral Consult with multiple disciplines and nutrition team members to develop optimal Provide oxygen and ventilatory plan of care. support as needed Identify appropriate interventions Urinary catheter Adjust and reprioritize plan of care Ensure availability of supplies for anticipated changes in condition ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Nursing Process (3 of 3) Evaluate Outcomes (Evaluation) Constantly evaluate client’s response to interventions Evaluate trends Evaluate lab values Evaluate assessment finding Improve Worsen Stay the same ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Shock: Treatments & Therapies Treatment is focused on supportive care IV Fluids Mechanical Ventilation Hemodynamic monitoring: Pulmonary artery catheter; central venous pressure; arterial line IV antibiotics Norepinephrine IV to manage Mean Arterial Pressure Blood and blood products Mechanical circulatory support: Intra-aortic balloon pump; left ventricular assist device; extracorporeal membrane oxygenation; cardiac transplant Nutrition Hemodynamic monitoring ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Hemodynamic Monitoring Arterial Pressure Monitoring Radial artery Displays waveform and constant blood pressure reading Allows health care team to see trends or abrupt changes in blood pressure. Can be used for frequent lab draws. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiac Tamponade: Pathophysiology An accumulation of fluid around the heart 3 Phases Phase 1: accumulated fluid in the pericardial space, ventricles harden and cannot relax Phase 2: CO is decreased due to SVP not filling the heart Phase 3: Decreased CO to the point of circulatory failure ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiac Tamponade: Etiology Central line placement Kidney failure Malignancies Leukemia Infection Heart failure Complications from MI Radiation to the chest Aortic dissection Previous high-risk surgery Aortic aneurysm Hypoparathyroidism ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiac Tamponade: Impact on Overall Anxiety Health Restlessness Difficulty breathing Heart failure Edema Bleeding Shock Death ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Cardiac Tamponade: Clinical Presentation Hypotension Jugular vein distention Muffled heart sounds ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Pulsus Paradoxus Can indicate pericardial effusion as cause of cardiac tamponade Fall of systolic blood pressure by greater than 10 mm Hg during inspiration ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Lab & Diagnostic Studies Echocardiogram Creatine kinase levels Electrocardiogram (ECG) Renal profile Chest X-Ray Coagulation studies Computerized Tomography (CT) Magnetic Resonance Imaging (MRI) Coronary Angiography Right Heart Catheterization ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Role of the Nurse Frequent assessments to determine change in condition Review health record Identify resources Safety assessment Awareness of own knowledge and skills required to care for client Provide education to client and care partners. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  The Nursing Process Recognize Cues (Assessment) Generate Solutions (Planning) Identify early subtle and apparent Collaborate with members of the changes to client’s condition health care team Analyze Cues (Analysis) Identify expected outcomes Identify client problems Create an evidence-based plan of care Establish needs/concerns Identify potential complications Take Actions (Implementation) Identify cues of immediate concern Implement appropriate nursing interventions Prioritize Hypotheses (Analysis) Organize client assessment Evaluate Outcomes (Evaluation) information according to changes, Improved patterns, and trends. Worsened Use standards of care and priority Stay the same setting frameworks to guide care. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Treatments and Therapies Position client in bed with feet elevated Provide oxygen Volume resuscitation Vasopressors Pericardiocentesis Surgery- pericardial window ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Coronary Artery Bypass Graft (CABG) Restores blood flow to the heart muscle caused by narrowing of the coronary arteries. Blood vessels are taken from a vein in the leg, chest, or arm and grafted onto a section of the aorta and an area distal to the coronary artery blockage. The graft opens the artery to allow a clear blood flow to the heart muscle. Multiple graphs are used if there are multiple blockages. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG Etiology Nonmodifiable risk factors for coronary artery disease Age Gender Family history Chronic conditions contribute to coronary artery disease and may result in the need for CABG surgery Diabetes Hypertension Hypercholesterolemia Obesity Unhealthy diet Smoking ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG: Impact on Overall Health Physiological Health Overall Health Incisional pain Spiritual Muscle pain Financial Throat pain Environmental Chest tube discomfort Intellectual Psychological Health Emotional Anxiety Physical Depression Social ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG: Lab and Diagnostic Studies CBC Liver enzymes Coagulation studies ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG: Role of the Nurse The nurse must consider a variety of factors when caring for a client going through a CABG procedure. Availability of resources Personnel Bed availability Pre-op factors Document lab work Informed consent History and physical Post-op factors Hemodynamic monitoring Recognize, minimize, manage and report any complications ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG: Nursing Process Recognize Cues (Assessment) Analyze Cues (Analysis) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  CABG: Treatments & Therapies Pharmacology IV therapy Statins Client teaching Antihyperglycemics Information regarding surgery Antihypertensives Incisional Care Antiplatelet therapy CAD risk factors Analgesics Medications Antibiotics When to seek emergency care Nutrition Cardiac rehabilitation Enteral nutrition within 24 hr post-op Hemodynamic monitoring ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Valve Replacement: Pathophysiology ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Replacement: Etiology Clients with valve disease are at Risk factors risk for: Age Stroke Family history Heart failure Congenital heart disease Blood clots cardiac arrest Obesity Death Lack of exercise Diabetes High cholesterol Hypertension Endocarditis Myocardial infarction Rheumatic fever ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Replacement: Impact on Overall Health High risk surgery especially if client is of advanced age with multiple comorbidities. Will the surgery positively or negatively impact quality of life? Why? ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Surgery: Clinical Presentation Shortness of breath Heart murmur Irregular heartbeat Chest pain Exhaustion Edema in the lower extremities ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Surgery: Role of the Nurse Communication Supply chain Staffing Client safety Prevention of medical errors Coping mechanisms Assess and treat pain Client education ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Surgery: Nursing Process Recognize Cues (Assessment) Analyze Cues (Analysis) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Valve Surgery: Treatments and Therapies Transcatheter Aortic Valve Implant (TAVR) Pharmacology Nutrition Hemodynamic Monitoring IV Therapy Client teaching ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Cardiopulmonary Arrest: Pathophysiology Electrical malfunction within the heart Sudden cessation of cardiac function Client stops breathing and becomes unresponsive Death occurs within minutes without intervention ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Rhythms Shockable Rhythms Non-shockable Rhythms Ventricular fibrillation Cardiac asystole Ventricular tachycardia Pulseless electrical activity ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Etiology Ischemic heart disease Hypovolemia Myocardial dysfunction Vasodilation that leads to septic shock Heart failure Cardiac tamponade Valvular heart disease Pulmonary embolism Airway obstruction ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Clinical Fatigue/Weakness Presentation Dizziness/Syncope Chest pain and Shortness of breath Vomiting Palpitations Backpain ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Lab and Diagnostic Studies Electrocardiogram Troponins Coronary Angiogram Creatinine Kinase Stress Test Arterial Blood Gases Chest X-Ray Brain Natriuretic Peptide (BNP) CT Scan of Chest Complete Blood Count Echocardiogram Metabolic Panel Lipid Panel Prothrombin Time Partial Thromboplastin Tine D-Dimer ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Role of the First responder Nurse Ensure IV access Medication administration Assist with oxygen delivery and ventilation Provide CPR Record time, rhythms, and actions during code Leader Client and family support ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Cardiopulmonary Arrest: Nursing Process Recognize Cues (Assessment) Analyze Cues (Analysis) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Cardiopulmonary Arrest: Treatment and Therapies Defibrillate IV Therapy Cardioversion Oxygen Therapy Medications Therapeutic Hypothermia Epinephrine Emergency medications during Amiodarone cardiac arrest (LEAN) Lidocaine L – Lidocaine Atropine E – Epinephrine Sodium Bicarbonate A – Atropine Calcium N – Narcan Magnesium Dextrose ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Abdominal Aortic Aneurysm: Pathophysiology ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Abdominal Aortic Aneurysm: Risk Factors Atherosclerosis Smoking Sex Family history Hypertension Coronary Artery Disease Peripheral Artery Disease Renal Insufficiency COPD CHF ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Abdominal Aortic Aneurysm: Clinical Presentation Most AAAs are associated with no Ruptured Aneurysm manifestations. Sudden onset back and abdominal pain AAA is usually discovered on Noticeable abdominal distention accident with an imaging scan for another issue. Signs and symptoms of hemorrhagic shock Client may have an audible bruit Cullen’s sign over aneurysm site Turner’s sign Pulsating abdominal mass Palpable abdominal mass ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Abdominal Aortic Aneurysm: Role of the Client teaching Nurse Provide emotional support ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Abdominal Aortic Aneurysm: Nursing Process Recognize Cues (Assessment) Analyze Cues (Analysis) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Abdominal Aortic Aneurysm: Treatments Statins and Therapies Beta blockers Iron supplements Supervised exercise program Respiratory therapy Smoking cessation Surgical Repair Endovascular Aneurysm Repair (EVAR) Open Aneurysm Repair ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved. Systemic Inflammatory Response Syndrome (SIRS) https://www.semanticscholar.org/paper/Systemic-inflammatory-response-syndrome-(SIRS)%3A-and-Matsuda- Hattori/9cfd3618033ca4062e12e09ee74d2b187588b49b ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  SIRS: Clinical Presentation Body temperature: less than 36° C or greater than 38° C Heart rate: greater than 90 bpm Tachypnea: greater than 20 bpm or PaCO2 less than 32 mm Hg WBC: less than 4,000/mm3 or greater than 12,000/mm3 or greater than 10% immature (band) forms ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  SIRS: Lab and Diagnostic Studies Blood cultures CBC PTT PT Platelets ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  SIRS: Role of the Nurse Assess client. Ensure hemodynamic stability. Communicate findings to provider and health care team. Prevent progression to shock; identify early and subtle findings. Provide client and family education. Assess client and family coping mechanisms. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  SIRS: Nursing Process Recognize Cues (Assessment) Analyze Cues (Analysis) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  SIRS: Treatments and Therapies Treatment focuses on underlying cause of SIRS Surgical interventions Wound debridement Abscess drainage Pharmacological treatments Gram positive and Gram-negative antibiotics Glucocorticoids Glucose control Vasopressors and Inotropes ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Multiple Organ Dysfunction Syndrome (MODS): Pathophysiology An extreme response after injury, sepsis or burns that leads to the constant release of immune mediators in the blood causing altered organ function and failure. Constant release of immune mediators results in oxidation stress causing an imbalance of antioxidants and free radicals. Decreased cellular oxygenation convert cells to anerobic metabolism which leads to lactic acidosis. The increase in metabolic acidosis leads to multiple organ dysfunction syndrome. MODS causes the break down of muscle tissue and vital organs. ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Risk Factors Chronic disease Pre-existing organ dysfunction Immunosuppressive therapy Extreme age Malnutrition Cancer Trauma Alcoholism Severe Trauma Sepsis ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Impact on Overall Health Infection is the leading cause of MODS after trauma Emergency situation High mortality (40% to 50%): Death rate increases as the number of involved organs increase Prolonged recovery can cause damaging effects to the aging adult ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Clinical Presentation Respiratory Hepatic Dyspnea leading to respiratory failure Increased bilirubin level (client requires intubation and mechanical ventilation) Gastrointestinal Infiltrates on chest X-Ray Nausea Vomiting blood Cardiovascular Tachycardia Integumentary Decreased blood pressure Impaired wound healing Arrhythmia Central Nervous System Decreased cardiac output Disorientation Renal Confusion Decreased urine output Anxiety Anuria (dialysis is required) Agitation Increased creatinine levels ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Lab and Diagnostic Studies Sequential Organ Failure Blood cultures Assessment (SOFA) score ABGs Chest X-Ray Electrolytes BUN/Creatinine CBC PT/PTT ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: SOFA Scale Sequential Organ Failure Assessment (SOFA) Respiration Coagulation Liver Cardiovascular Central nervous system Renal ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Role of the Nurse Update the health care team on client’s condition Reposition client every 2 hours Provide comfort Frequent assessment Utilize clinical judgment Identify evidence-based solutions for the delivery of optimal care Client and family education ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: The Nursing Process Recognize Cues (Assessment) Analyze Cues (Assessment) Prioritize Hypotheses (Analysis) Generate Solutions (Planning) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  MODS: Treatments and Therapies Antibiotics Sedation Mechanical Ventilation IV Fluids Medications Nutrition Hemodynamic Monitoring ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: Risk Factors Pregnancy complications Blood infections Cancer Blood transfusion reaction Liver dysfunction Shock Trauma Burns ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  Blood Product Transfusion Typical response Abnormal response Small variations in vital signs Hives/itching Usually no reaction Mild allergic reaction Fever/chills Febrile non-hemolytic reaction Acute/hemolytic reaction Bacterial contamination Hypotension Acute/hemolytic reaction Bacterial contamination Anaphylactic reaction Acute lung injury Dyspnea Anaphylactic reaction Acute lung injury Volume overload ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: Clinical Presentation Bleeding around wounds, at surgical sites, and venipuncture sites Ecchymosis Hematoma Petechiae Tissue necrosis Dyspnea Epistaxis Conjunctival bleeding ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: Lab and Diagnostic Testing PT/PTT (increased) D-Dimer (increased) Fibrinogen (decreased) Platelet count (decreased) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: Role of the Nurse Verify that lab tests have been done Frequent assessments for bleeding Collaborate with members of the health care team Oxygen therapy Client/Family education and support Goals of care Optimal oxygen delivery Reversal of clotting Prevent further injury Hypovolemic shock Cardiac arrest Organ damage Loss of limb ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: The Nursing Process Recognize Cues (Assessment) Analyze Cues (Assessment) Prioritize Hypotheses (Analysis) Generate Solutions (Planning ) Take Actions (Implementation) Evaluate Outcomes (Evaluation) ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.  DIC: Treatments and Therapies Fresh frozen plasma Whole blood Anticoagulants IV Fluids ‹#› Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.