A pregnant client at 28 weeks gestation is diagnosed with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Which nursing intervention should be the highest priority?
1Monitor for signs of bleeding and prepare for immediate delivery✓ 정답
2Administer heparin as prescribed to prevent further clot formation
3Encourage ambulation to prevent venous thromboembolism
4Increase fluid intake to maintain adequate hydration
해설
The priority is monitoring for bleeding and preparing for immediate delivery to remove the underlying cause of DIC (severe preeclampsia). Other options like heparin or ambulation are inappropriate in this context.
Understanding the Clinical Scenario
The client is at 28 weeks gestation with severe preeclampsia, a condition of widespread endothelial dysfunction, and has now developed disseminated intravascular coagulation (DIC). DIC is a life-threatening, acquired disorder characterized by the systemic activation of the coagulation cascade. This process leads to the simultaneous formation of microthrombi in the vasculature and the consumption of platelets and clotting factors, which paradoxically results in severe hemorrhage. In the context of pregnancy, particularly when complicated by a placental disorder like abruption or severe preeclampsia, the underlying pathophysiology is linked to the release of thromboplastic substances from the damaged placenta into the maternal circulation, triggering this massive consumptive coagulopathy .
Analysis of the Priority Intervention
The highest priority nursing intervention is to monitor for signs of bleeding and prepare for immediate delivery. The rationale is rooted in the pathophysiology of DIC and its obstetrical trigger. In a client with severe preeclampsia, the placenta is the diseased organ. The development of DIC signals a critical escalation where the maternal condition is rapidly deteriorating due to the ongoing release of thromboplastin from the placental bed. The definitive treatment to halt the underlying disease process and stop the consumption of clotting factors is to remove the source, which is the placenta and the products of conception. Therefore, preparing for immediate delivery is not just a treatment option; it is the causal intervention that addresses the root cause of the DIC. Simultaneously, vigilant monitoring for bleeding is paramount because the consumptive phase of DIC leaves the client at extreme risk for hemorrhage from any site, including venipuncture sites, mucous membranes, and the uterus itself .
Why the Other Options Are Incorrect
- Option 2: Administer heparin as prescribed to prevent further clot formation. While DIC involves pathological clot formation, the administration of heparin is generally contraindicated in the acute, hemorrhagic phase of DIC, especially when delivery is imminent or ongoing. The primary clinical manifestation in this scenario is a high risk of massive hemorrhage due to depleted clotting factors, and heparin would dangerously exacerbate this bleeding risk. The priority is to stop the consumption by delivering the placenta, not to pharmacologically inhibit coagulation.
- Option 3: Encourage ambulation to prevent venous thromboembolism. This intervention is contraindicated. A client with severe preeclampsia and active DIC is hemodynamically unstable and at high risk for catastrophic hemorrhage and seizures (eclampsia). Strict bed rest is required to decrease metabolic demand and minimize the risk of injury and bleeding. Ambulation would dangerously increase the risk of a fall and intracranial or intra-abdominal hemorrhage.
- Option 4: Increase fluid intake to maintain adequate hydration. While maintaining intravascular volume is a critical component of supportive care in DIC, simply encouraging oral fluid intake is a grossly inadequate and low-priority intervention. This client requires aggressive intravenous fluid resuscitation and blood product replacement (e.g., fresh frozen plasma, cryoprecipitate, platelets) to manage hypovolemia and restore clotting factors. This is a supporting measure, whereas addressing the source of the DIC through delivery preparation is the definitive, highest-priority action .
Clinical Assessment
Client is at 28 weeks gestation with severe preeclampsia.
New diagnosis of Disseminated Intravascular Coagulation (DIC).
Monitor for oozing from IV sites, petechiae, hematuria, and epistaxis.
Assess for signs of placental abruption (vaginal bleeding, uterine tenderness).
Priority Nursing Actions
Prepare for Immediate Delivery: Notify the provider and prepare the client for an emergency cesarean section, as delivery is the definitive treatment to halt the DIC process.
Hemorrhage Surveillance: Continuously monitor vital signs, perform serial fundal checks, and assess for any signs of external or internal bleeding.
Administer Blood Products: Prepare to transfuse packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets per massive transfusion protocol to replace consumed factors.
Contraindicated Interventions
Heparin Administration: Generally contraindicated in acute obstetric DIC as it does not remove the trigger and can exacerbate hemorrhage.
Ambulation: Strict bedrest is required to minimize oxygen consumption and prevent injury due to high bleeding risk.
Key Monitoring Parameters
Serial labs: CBC, fibrinogen, D-dimer, PT/INR, aPTT.
Intake and output; assess for oliguria indicating renal compromise.
Continuous fetal heart rate monitoring if not an immediate surgical candidate.
Disseminated Intravascular Coagulation — Disseminated intravascular coagulation. A life-threatening condition in which abnormal blood clot formation occurs extensively in small blood vessels throughout the body, while simultaneously consuming clotting factors and platelets, leading to a tendency for bleeding.
Preeclampsia — Preeclampsia. It is a pregnancy complication characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. If it progresses to severe form, it can cause fatal complications such as liver, kidney, brain dysfunction, and DIC.
Placental Abruption — Placental abruption. A condition in which the placenta partially or completely separates from the uterine wall before delivery, one of the major complications of severe preeclampsia and a common cause of DIC.
Fibrinogen — Fibrinogen. A protein essential for blood clotting, it is consumed as DIC progresses, causing levels to drop sharply. Low fibrinogen levels are an important indicator of active DIC and increased bleeding risk.
Massive Transfusion Protocol — Massive transfusion protocol. A systematic procedure pre-established by hospitals to rapidly supply blood products (packed red blood cells, fresh frozen plasma, platelets) in a fixed ratio to patients with severe bleeding. It is used in the management of obstetric massive hemorrhage or DIC.