M4 Clotting Flashcards
DIC
Disseminated Intravascular coagulation
Inflammation and coagulation due to initial disease process causes microthrombi to form in circulation.
This uses up fibrinogen and platelets causing both excessive clotting and bleading
Initial processes that may cause DIC
Sepsis
Cancer
Trauma
Shock
Abruptio Placentae
Due to excessive microthrombi in dic, the primary reflection on the body is
multiple organ failure due to ischemia
To correct the ischemia with DIC body will release more potent anticoagulants, this will cause
labs
Further bleeding
Elevated fibrin degradation products and D-dimers
1st manifestation of DIC
progressive decrease in platelet count
After the organ failure and happens due to excess clotting with DIC, _ starts
bleeding
DIC bleeding sights
IV sight
Visual changes!
Mucous membranes
GI and Urinary tract
DIC clotting and integument
temp and sensation v
pain ^
cyanosis
superficial gangrene
DIC bleeding and integument
Petechiae, including periorbital and mucosa
bleeding gums, iv sites, previous injections
epistaxis, ecchymoses, joint pain
DIC clotting and circulation
Pulse v
Capillary fill time greater than 3 sec
DIC bleeding and circulation
Tachycardia
DIC clotting and resp system
Hypoxia - clotting in lungs
Dyspnea
CHEST PAIN (on INSPIRATION)
ULTIMATE SHOCK
DIC bleeding and resp system
High-pitched bronchial sounds
Tachypnea
Acute respiratory distress ARDS
DIC clotting and GI
Pain
Heartburn
DIC bleeding and GI
Hematemesis
Melena
Retroperitoneal bleeding - firm abdomen, distention, tender on palpation,
abdominal girth INCREASE
DIC clotting and renal
Urine output v
BUN ^
Creatinine ^
DIC bleeding and renal
Hematuria
DIC clotting and neuro
v LOC
v pupil reaction
v strength/mobility
DIC bleeding and neuro
Anxiety restlessness
HA
LOC change!
Conjunctival hemorrhage
Platelet count
Changes with DIC
150,000-450,000mm
v with DIC
PT time
Changes with DIC
11-12.5s
^ with DIC
aPTT time
Changes with DIC
23-35s
^ with DIC
Thrombin time TT
Changes with DIC
8-11s
^ with DIC
Fibrinogen level
Changes with DIC
170-340mg/dL
v with DIC
D-dimer level
Changes with DIC
0-250ng/ml
^ with DIC
FDP level
fibrin degradation product
Changes with DIC
0-5mcg/ml
^ with DIC
Euglobulin clot lysis time
Changes with DIC
Greater than 2h
Less than 1h with DIC
DIC scoring system
Platelets
FDP
Prothrombin time
Fibrinogen
0 1 2 3
Platelet
0->100,000
1-50,000 to 100,000
2-< 50,000
FDP
0-no increase
2-moderate increase
3-stronge increase
Prothrombin
0-<3s
1-3s to 6s
2->6s
Fibrinogen
0->100mg/dL
1-<100mg/dL
Most critical factor in DIC treatment
UNDERLYING CAUSE
Correct tissue ischemia with DIC via
O2
Fluid replacement
Correct Lyte abnormalities
Administer vasopressor meds
Vasopressor meds
Create pressure in vessels - hence vasopressor
constricts vessels
Vasopressor med names
Vasopressin
Phenylephrine
Correct hemorrhage with DIC
Replace platelets and coagulation factors
Cryoprecipitate -replaces fibrinogen factor V and VII
Decision to do transfusion support for DIC is based on
risk of bleeding out from puncture
Nursing, how to ID pt at risk of DIC
ID PT at risk via clotting/bleeding symptoms or labs
Most vulnerable organs in need of support due to DIC ischemia
Kidneys
Lungs
Brain
Skin
Treat DIC kidney injury
Dialysis
Dialysis needs a large bore catheter so for DIC PTs also give _ and _ with this treatment
Platelets
Plasma
Respiratory nursing interventions for DIC
Lungs may fill with blood so…
Suction as gently as possible to prevent more bleeding
ITP
Immune Thrombocytopenic Purpura
other names
what is it
Idiopathic TP is AUTOIMMUNE!!!
Platelet count less than 100,000mm with no explanation
Primary (autoimmune) ITP cause
Pathologic antiplatelet antibodies
Impaired production of megakaryocytes
T-cell mediated destruction or platelets
Secondary ITP cause
Other autoimmune disorders
Viral infection
Drugs
Other autoimmune disorder that can cause ITP
Antiphospholipid antibody syndrome
RA
Viral infections that can cause ITP
Hepatitis C
HIV
Helicobacter pylori
Meds that can cause ITP
Cephalosporins - antimicrobials start with (cef-ceph) cefdinir, cephalexin/kelfex
Sulfonamides - antibiotics
Bactrim, Septra, Cotrim
Furosemide
Once platelets are marked for destruction by the body they are destroyed by which system
Reticuloendothelial system
RES
Body attempts to compensate for platelet destruction by
Increasing production in bone marrow
minor S/S of thrombocytopenia
ITP
easy bruising
heavy menses
petechiae
major S/S of thrombocytopenia ITP
GI bleeding
Respiratory system bleeding
aka Wet Purpura
Risk factors for severe bleeding
Platelet count less than 20,000
History of bleeding episodes
Advanced age
Correlation between H.pylori and ITP
Not clear
Diagnosing ITP involves
Tests to rule out other causes like
HepC
HIV
Bone marrow aspirate
H pylori
Risk of bleeding increases when platelet count drops to
30,000mm
In ITP below 30,000 treat _ _ not _
Decision to treat is based on _ not …
Platelet count, not disease
Bleeding, not platelet count
is quinine associated with ITP
YES
Can you give transfusions to ITP patients
NO
those platelets will die too but you will increase fluid volume and so bleeding into lungs and GI
Emergency med for ITP
Aminocaproic acid
Fibrinolytic enzyme inhibitor
slows destruction of clots
Mainstay short term therapy for ITP
work on what cell
Immunosuppressive agents
Macrophages
ITP corticosteroids for adults
Dexamethasone
Prednisone
Corticosteroids will increase platelet count within…
good for long term use
a few days
NO
Surgery for ITP
why
Splenectomy
removes site of autoantibody production
Side effects of splenectomy for ITP
risk for thrombocytopenia below 30,000
Splenectomy lowers immune system so pt will need to be on top of _
do which once prior to procedure?
Shots!
pneumococcal
influenza
meningococcal
Nursing management ITP
pt Hx
Lifestyle (sedentary better)
OTC meds, herbs, supplements that can increase bleeding
What meds increase bleeding
Sulfa drugs
Aspirin
NSAIDs
Other history of complications ITP
indicates
Headaches
Visual disturbances
Viral illnesses
Indicates intracranial bleeding
With wet purpura on admission do
Neuro assessment
Avoid what procedures with ITP
Injections
Rectal meds
ITP patients may experience what unrelated symptom
Fatigue
Teach ITP pt to know
Med side effects
Platelet count monitoring
Follow-up appt
ADL recommendations for ITP
avoid constipation
use soft toothbrush
electric razor
ITP and corticosteroid complications
Osteoporosis
Proximal muscle wasting
Cataract formation
Dental carries
Supplements for ITP
Calcium
VitD
Bisphosphonate
HELLP acronym
H-hemolysis
EL-elevated liver enzymes
LP-low platelet count
HELLP 101
Life threatening pregnancy complications
Variant of preeclampsia
HELLP symptoms can be mistake for
gastritis
flu
hepatitis
bladder problems
Common cause of HELLP
Preeclampsia
Pregnancy induced hypertension
Previous pregnancy with HELLP…
increases risk
Other HELLP Risk factors
Age over 25
Caucasian
Multiparous
HELLP S/S
Preeclampsia
Indigestion
Pain in upper right quadrant (LIVER distention)
Shoulder pain
HELLP/preeclampsia S/S
Headache
NV
Bleeding
Vision changes
Swelling
Biggest signs of HELLP Preeclampsia
High BP
Proteinuria
Most common reason for morality with HELLP
Liver rupture
Stroke - cerebral edema, cerebral hemorrhage
HELLP severity is based on
Platelet count
Mild
Moderate
Severe
HELLP platelet numbers
Mild, class III- 150,000 to 100,000mm
Moderate, class II- 100,000 to 50,000mm
Severe, class III- less than 50,000
HELLP prevention
Good health before pregnancy
Regular prenatal visits
Inform Dr. if Hx of preeclampsia, hypertension or HELLP
Education regarding S/S
HELLP Treatment UNDER 34 weeks
Admission and bedrest
Corticosteroids (for baby lungs)
Magnesium sulfate (prevent seizures)
Blood transfusion (if low pltlt count)
Fetal monitoring
Fetal monitoring
Biophysical test
Sonogram
Nonstress test
Fetal movement
HELLP Treatment OVER 34 weeks
Delivery is recommended course of treatment
Trial of labor TOL
Surgery may cause complications due to low plt count
HELLP affects on baby
Baby’s over 2 pounds have an increased chance of survival, under 2 have a significant decrease
Death due to abruption of placenta and asphyxia
Most serious complications of HELLP
Placenta Abruption
Pulmonary edema
DIC
ARDS
Renal failure
Diagnosing HELLP
hemolysis
RBC death
Abnormal peripheral smear
Bilirubin less than 1.2mg/dl
Diagnosing HELLP
Elevated Liver enzymes
Serum aspartate aminotransferase > 70U/L
Lactate dehydrogenase > 600U/L
Diagnosing HELLP
Low Platelets
Less than 150,000
and lower determines severity
HELLP PT needs daily
WEIGHT
to monitor HELLP renal function
indwelling cath
Do abdominal palpations for HELLP
checks on
Uterine tone
Fetal sieze
Activity
Position
Fetal checks for HELLP
NST
BPP
checks for hypoxia due to placental insufficiency
Electronic monitoring for HELLP fetal status is done at what rate
At least daily
HELLP PT room should be near nurses station and have
emergency drugs
crash cart
seizure precautions
Due to HELLP bedrest pt is at risk of _
intervetions
Thromboembolisms
TED hose
SCD boots
If severe pulmonary edema and renal failure with HELLP pt will need invasive hemodynamic monitoring for fluid volume. AKA
Swan Ganz Catheter
HIT
Heparin Induced Thrombocytopenia
Patho/causes
Due to LMWH
Platelet factor 4 Binds to LMWH - platelets activate increasing thrombosis - platelets are consumed and macrophages or the RES start to attack existing thrombi - Result is THROMBOCYTOPENIA
Risk of LMWH HIT is _%
5%
HIT T1 101
Mild
Onset 1-4 days
100,000 platelet count
HIT T2 101
Life threatening
Onset 5-10 days
IgG Antibodies
60,000 platelet count
S/S of HIT
Skin necrosis at injection syte
Fever, chills, tachycardia, dyspnea
Limb ischemia
Organ infarction
PF4 testing in HIT
ELISA
Colorimetric change OD
Functional assay HIT testing
Serotonin release assay
SRA
4Ts of Thrombocytopenia and HIT
Thrombocytopenia - drop in CBC and platelet count
Timing - fall, 5-10 days after heparin initiation
Thrombosis - venous/arterial
no oTher explanations
HIT Treatment
STOP Heparin
Give Protamine sulfate
Hx of complications that may impact blood transufsion
Multiple births
Cardiac
Pulmonary
Vascular
problems
Before starting transfusion do a
Why
Full body assessment
Vitals
fluid status
lungs for clearance
cardiac for edema hf
skin for petechiae ecchymoses
This will help differentiate a reaction if there is one
Febrile nonhemolytic reaction
Most common reaction
caused by antibodies reaction to donor leukocytes
Febrile Nonhemolytic reaction and birth
can happen to Rh negative moms who have Rh positive babys
Febrile Nonhemolytic reactions and frequent transfusions
Increase chance due to increased exposure to different leukocytes
For blood transfusion use special tubing that has
filter for clots
Double check blood with
what to check
another nurse
ABO group
Rh type
Check blood for
Gas bubbles
Unusual color
Cloudiness
Start transfusion with _min of removing blood from bank
30
For first 15 min of transfusion run at
5ml/min
then can increase
Monitor closely up to
30 min
Transfusions can not exceed _h
4
Change tubing after every _ unites
2
With at risk patients monitor for at list _h for TACO
6h
Transfusion Associated Circulatory Overload
Fresh Flozen plasma is to be infused over
Before getting from bank start
30-60min
line
Fresh Frozen Plasma Needle gauge
22 or large
Febrile Nonhemolytic reaction S/S
chills
fever
muscle stiffness
Febrile nonhemolytic reaction lifethreatening?
how long to onset
Scary for PT
NO
2h after start of infusion
YES
Med for Febrile nonhemolytic reaction
can you give it prophylactical ?
Tylenol
NO, may mask more serious complications
Acute hemolytic reactions
Donor blood is incompatible
of ABO (more severe) or Rh (less severe)
MOST DANGEROUS
Acute Hemolytic Reactions occur in transfer of as little as
10ml of blood
First 15min
Acute Hemolytic Reaction mild S/S
Fever
Chills
Lower back pain
Chest tightness
Dyspnea
Nausea
As RBCs are destroyed in acute reaction, hemoglobin will get filtered through urine resulting in
Hemoglobinuria
Acute Hemolytic reaction severe S/S
Hypotension
Bronchospasms
Vascular collapse
Acute Hemolytic reaction Consequences
AKI
DIC
Blood allergic reaction
Urticaria (hives)
Itching
Flushing
during transfusion
Treatment for Allergic reaction to blood
Stop
Give
Antihistamines
Notify
If Blood allergy is severe with
Bronchospasms
Laryngeal edema
Shock
give
Epinephrine
Corticosteroids
Vasopressor
TACO
Transfusion associated circulatory overload
Hypervolemia due too fast infusion of large volume
PT at risk of TACO
HF
Renal failure
Advanced age
MI
For patients who have a high initial volume and are at risk of TACO, give
PRBCs
Meds to give to lower hypervolemia before initiating transfusion
Diuretics
S/S of TACO
Dyspnea
Orthopnea
^BP
JVD
Pulmonary edema
Coughing pink sputum
Body position in a fluid overload
Upright
Feet in dependent position
How long can it take for TACO to develop
As late as 6h
Treating dyspnea with TACO admin
Morphine
Oxygen
When do blood contamination S/S occure
A few hours after completion of transfusion
S/S of blood contamination
Fever
Chills
Hypotension
infection
Treatment for blood contamination transfusion
Fluids
Broad-spectrum antibiotics
Corticosteroids
Vasopressors
What can occur due to contaminated blood
Sepsis
TRALI
Transfusion Related Acute Lung Injury
Most common cause of TRANSFUSION RELATED DEATH
idiosyncratic (dont know why it happened)
Onset of TRALI
Within 6h of transfusion
Most often within 2
S/S of TRALI
SOB
Hypoxia
SpO2 less than 90
hypotension
fever
pulmonary edema
Treatment for TRALI
Aggressive supportive therapy
O2
Intubation
Fluids
TRALI is more likely with transfusion of
Plasma
Platelets
Prevent TRALI by
Limiting frequency and amount transfused
Delayed hemolytic reactions 101
Occur within 14 days
Fever
Anemia
^ Bilirubin
Jaundice
non lifethreatening
Delayed hemolytic reactions indicated
A potential for more serious reactions in the future
Other transfusion complication
Iron overload
damages
liver, heart, testes, pancreas
Treat iron overload
Iron Chelation
What to do first if reaction occurs
STOP Transfusion
Start normal saline through new tubing
After stopping transfusion
Assess pt
Vitals
O2
Resp status
Breath sounds
chills
JVD
back pain
urticaria
After assessing transfusion pt
Notify provider and implement next plan
Notify blood bank
send blood container back to blood bank
DOCUMENT
If a hemolytic transfusion reaction of bacterial infection is suspected the nurse will
obtain blood specimen from pt
collect urine
document reaction according to institution policy
Alternatives to blood transfusion
Growth factor
Erythropoietin
G-CSF
GM-CSF
Thrombopoietin
Thrombopoietin
helps platelet formation
G-CSF
neutrophil stem cells
improves neutropenia
good for chemo
GM-CSF
Increases RBCs
Platelets
Monocytes
1 contributing factor to DIC
Sepsis
Coagulation cascade?
?
Prothrombin and thrombin are what factor
10
DIC 101
Massive activation of coagulation cascades
Uses up all coagulation factors
PT bleeds out
DIC leads to MODS
Multi Organ Disfunction Syndrome
Inotropic drugs for DIC?
?
DIC nursing diagnosis
Impaired perfusion
Heparin drip =
if dropping
Monitor platelet count
TELL PHYSICIAN
When to immediately stop heparin to prevent HIT
Platelet drop by half or more
HIT can occure within hours of
RE EXPOSURE to heparin
Drug to give HIT give hit patients
Argatroban
HELLP is a life threatening _ complications
Pregnancy
Defining pain of HELLP
Right upper abdominal quadrant or epigastric pain
LDH
Lactate dehydrogenase
Greater than 60u/L
Lethal
Difference between preeclampsia and eclampsia
having a seizure
Mag sulfate and ECG change
Watch for widened QRS
HELLP can lead to what complication
DIC
HELLP with mom at 34 weeks
before 27 weeks
deliver
still deliver but in 48 to 72 hours after giving corticosteroids and surfactant for baby lung maturity
Purpura
Bruising
A lot of ITP pts have no
SYMPTOMS
Treatment of choice for ITP
Corticosteroid prednisone
IVIG
Red flag meds for ITP
Sulfa
NSAIDs
Aspirin
Can student work with blood
NO
Why is whole blood rarely given
Fluid volume overload in MINUTES
SO you only need to give them what they need
4 components of whole blood
RBC
Plasma
Platelets
Albumin
When to transfuse patients
Why
ONLY when symptomatic
even if labs are low
Transfusions are high risk
Giving blood to the bank is called a
Standard donation
Giving blood to a family member is called
Direct
Giving blood to self for future surgery
???
Collecting blood during surgery, cleaning, and reinfusing
Intraoperative Blood salvage
Pulling blood out, and exchanging it with solution. Then reinfusing if needed
Hemodilution transfusion
Before transfusing blood we need
Get order
Teach
Get consent
Type and cross
When pulling blood who is involved
Lab tech
2 RNs
Universal doner
O-
Kidneys let bone marrow know to produce
erythropoietin
Synthetic erythropoietin given to ESRD
Epoietin
After a hemolytic reaction and disconnecting the blood what to do with the IV port
Aspirate left over blood out
Start NS to keep line open
Only thing to ever hang with blood
NORMAL SALINE
One of the most important things to do after staring transfusion
DOCUMENT
When to document
Contemporaneous charting
Chart it when you do it
