A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Tissue Perfusion. Which action is inappropriate for this nursing diagnosis?

Question

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.

Answer 1

Answer: B

Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. 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.