Lippincott Certification Review Medical-Surgical Nursing

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Chapter 8

●● Next, the nurse uses palpation . ●● Palpate peripheral pulses, noting strength, rhythm, and rate. ●● Palpate the lymph nodes, noting temperature, consistency, mobility, shape, size, and tenderness; compare nodes on one side of the body with those on the other side. ●● Palpate the abdomen, noting tenderness, ascites, or enlarged organs. ●● Then the nurse auscultates . ●● Listen to heart sounds, noting abnormal sounds, rhythms, bradycardia, or tachycardia. ●● Auscultate the abdomen, noting bowel sounds, bruits, or venous hums. ●● Listen to all lung fields, noting any abnormal sounds. ●● The nurse then uses percussion . ●● Percuss the liver and spleen to estimate size. ●● Note the size and location of other abdominal organs. Anemias ●● Anemia exists when the body does not have enough RBCs or when RBCs do not have enough hemoglobin. ●● Types of anemia include blood loss or hemolysis and aplastic, iron deficiency, and megaloblastic anemias (see Types of anemia , pages 121–123). Disseminated Intravascular Coagulation ●● Description ●● Disseminated intravascular coagulation (DIC) is a serious blood coagulation disorder that occurs as a complication of conditions that accelerate blood clotting. ●● DIC is characterized by suppression of the fibrinolytic system and the development of small clots in the microcirculation, which consume clotting factors, resulting in excessive bleeding. ●● The disorder can result from septicemia, obstetric complications (abruptio placentae and amniotic fluid embolism), cancer, blood transfusion reactions, and liver disease. ●● Altered tissue profusion and multiple organ failure can occur; the mortality rate can exceed 50%. ●● Signs and symptoms ●● The main sign is abnormal bleeding, evidenced by cutaneous oozing, petechiae, ecchymosis, hematomas, gastrointestinal (GI) bleeding, and bleeding from wounds and IV sites. ●● Signs of organ compromise include dyspnea, oliguria, and muscle or abdominal pain; shock can also occur. ●● Diagnosis and treatment

●● Laboratory tests show a steadily decreasing platelet count; elevated prothrombin time (PT), partial thromboplastin time (PTT), plasma d-dimer, and fibrin degradation products; and decreased hemoglobin and hematocrit. ●● Medical management aims to identify and treat the underlying disorder, promote oxygenation, replace fluids and electrolytes, and provide hemodynamic support. ●● Treatments include platelets, cryoprecipitate, and fresh frozen plasma. ●● Nursing interventions ●● Early recognition of DIC improves patient outcomes; closely monitor for signs and symptoms of patients at risk. ●● When a patient has DIC, avoid trauma to skin or wounds to minimize bleeding, protect the patient from injury, and avoid dislodging clots. ●● Apply pressure to puncture sites until bleeding stops. ●● Monitor the patient’s vital signs, and administer IV fluids and blood products as ordered. ●● Monitor the patient’s intake and output carefully and record blood loss. ●● Watch for signs of tissue ischemia and failure. ●● Provide emotional support to the patient and family. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.