Shock - DIC and PIH - (1)

Disseminated Intravascular Coagulation (DIC)

Overview

• Definition: DIC is characterized by widespread intravascular clotting and bleeding.

• Causes: It is commonly initiated by endothelial damage or the release of tissue factor.

• Pathophysiology:

  • Excess thrombin is generated, leading to widespread clotting.

  • Results in ischemia, infarction, and necrosis of tissues.

  • Overwhelms clotting factors, continuing the cycle of bleeding.

• Common Situations: Frequently occurs alongside severe sepsis and septic shock.

Pathophysiology of DIC

• Injury Response:

  • Endothelial damage and tissue factor release activate the intrinsic and extrinsic pathways of coagulation.

  • Massive thrombin release prompts intravascular coagulation.

• Consequences:

  • Leads to vascular occlusion and tissue ischemia.

  • Increased consumption of clotting factors and activation of the fibrinolytic pathway causes diffuse bleeding.

Manifestations

• Complications:

  • Initial inflammatory response prompts clotting, followed by fibrinolysis.

  • Depletion of platelets occurs due to their consumption in clot formation.

• Bleeding: Development of bleeding as a significant manifestation of DIC.

Laboratory Findings in DIC

• Platelet Count: Decreased.

• Fibrinogen Level: Decreased.

• PTT: Increased sensitivity.

• PT: Increased sensitivity.

• D-Dimer: Elevated levels.

• Fibrin Split Products (FSP): Elevated.

Management of DIC

• Focus: Must concentrate on identifying and treating the underlying cause.

  • If infection is present, administer antibiotics.

• Bleeding Management:

  • Fresh Frozen Plasma (FFP) and platelets are given to replenish clotting factors.

  • Low-dose heparin may be utilized to balance for pathway deficiencies.

Nursing Considerations

• Continuous assessment of all body systems is essential due to the widespread impact of DIC.

• Implement bleeding precautions during patient care.

• Lab Monitoring: Regular checks on BUN, creatinine, arterial blood gases (ABG), urine analysis, and hemoccult tests.

Pregnancy-Related Hypertension

Chronic Hypertension

• Description: Present before pregnancy or diagnosed before 20 weeks gestation.

• Continuation: Persists beyond 42 days postpartum.

• Criteria: Systolic BP > 140 mmHg and diastolic BP > 90 mmHg.

Gestational Hypertension

• Description: Onset occurs after 20 weeks gestation, resolving within 12 weeks postpartum.

• Features: SBP > 140 mmHg and DBP > 90 mmHg without proteinuria.

• Diagnosis: Conducted retrospectively if transient.

Preeclampsia

• Definition: A significant condition during pregnancy indicating maternal vasospasm and possible hypoperfusion to the fetus.

• Symptoms: May include headache, visual disturbances, and hyperreflexia.

• Connection to DIC: Associated vascular endothelial damage can lead to DIC.

Comparison Chart: Preeclampsia vs. Eclampsia

• Mild Preeclampsia: BP > 140/90 mmHg, proteinuria 300 mg/24 hr.

• Severe Preeclampsia: BP > 160/110 mmHg, proteinuria > 500 mg/24 hr.

• Eclampsia: Causes seizures, with marked proteinuria.

Medical Management

• Antepartum: Emphasizes bed rest, frequent BP checks, daily weight, and urine protein monitoring.

• Intrapartum: Requires continuous fetal monitoring.

• Postpartum: Patients generally improve rapidly after delivery, though seizures can still occur for up to 48 hours post-delivery.

Fetal-Neonatal Risks

• Effects: Increased risk for small gestational age (SGA), sedation at birth.

• Hypermagnesemia: Related to maternal magnesium sulfate treatment.

Clinical Management for Pregnancy-Related Hypertension

• Strategies:

  • Promote bed rest, monitor vital signs, and restrict sodium intake.

  • Administer magnesium sulfate, frequent BP monitoring required.

• Immediate Care: Emergent delivery may be necessary if fetal distress is present.

HELLP Syndrome

• Definition: Stands for hemolysis, elevated liver enzymes, and low platelets.

• Association: Recognized as a complication in conditions like preeclampsia and eclampsia, often presenting in the third trimester.

• Symptoms: Severe right upper quadrant pain, nausea, and liver distention related to DIC.

Medications for Hypertension

• Common Medications: Include Magnesium Sulfate, Calcium Gluconate, Hydralazine, Labetalol, and Nifedipine.

• Dosing: Must follow specific protocols to ensure safety and effectiveness.

Nursing Assessment for Hypertension in Pregnancy

• Watch for:

  • Headaches, visual changes, decreased urine output, and weight gain.

  • Elevate BP readings indicating potential complications.

Eclampsia Overview

• Definition: Characterized by seizures or coma during pregnancy in patients showing signs of preeclampsia.

• Monitoring Needs: Keen observation for fetal hypoxia and possible complications such as cerebral hemorrhage.