While caring for a patient with sepsis, the nurse suspects that disseminated intravascular coagulation is developing
What did the nurse assess in the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cyanosis of the fingers
2. Patient complains of finger pain
3. Diminished pulses
4. New onset of confusion
5. Urine output 60 mL/hr
1,2,3,4
Rationale 1: Occlusion of blood vessels may be seen as cyanosis and/or gangrene, especially of the digits. There may actually be a demarcation line between the viable and necrotic tissue visible on the fingers or toes, and the patient may complain of pain in the digits.
Rationale 2: Occlusion of blood vessels may be seen as cyanosis and the patient may complain of pain in the digits.
Rationale 3: Diminished pulses are an indication of disseminated intravascular coagulation.
Rationale 4: Inadequate perfusion of the brain may present as an altered level of consciousness, especially confusion.
Rationale 5: An increase in urine output is not an indication of disseminated intravascular coagulation.
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