A client with disseminated intravascular coagulation (DIC)has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.
A)Monitor the client's level of consciousness and mental status.
B)Elevate the client's knees on the bed or with a pillow.
C)Minimize the use of tape on the client's skin.
D)Assess extremity pulses, warmth, and capillary refill.
E)Carefully reposition the client at least every 2 hours.

Question

Quizplus · Accepted Answer

A)Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.
B)Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.
C)Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding
D)Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.
E)Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.

A Client with Disseminated Intravascular Coagulation (DIC)has a Nursing Diagnosis