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Difficulty: HardReduction of Risk Potential

A practical nurse is reviewing the morning data for a client who has been receiving a continuous intravenous heparin infusion for the past four days to treat a deep vein thrombosis. Which finding represents the greatest physiological risk to the client and requires immediate escalation to the registered nurse?

  1. A morning platelet count that has decreased from 210,000/mm3210,000/\text{mm}^3 to 95,000/mm395,000/\text{mm}^3.Answer
  2. B
    An activated partial thromboplastin time (aPTT) of 68 seconds68\text{ seconds}.
  3. C
    The presence of multiple small ecchymoses around recent peripheral intravenous puncture sites.
  4. D
    A resting heart rate of 92 beats/min92\text{ beats/min} with a blood pressure of 116/72 mm Hg116/72\text{ mm Hg}.

Answer

The morning platelet count that has decreased from 210,000/mm3210,000/\text{mm}^3 to 95,000/mm395,000/\text{mm}^3.
The correct answer identifies the significant decrease in the platelet count. A drop in platelets by more than 50% or a decline below 150,000/mm3150,000/\text{mm}^3 in a client receiving heparin is a primary indicator of heparin-induced thrombocytopenia (HIT). This paradoxical immune reaction causes widespread microthrombi and severe vascular complications. It requires immediate escalation to the registered nurse so the heparin infusion can be stopped promptly.

Step-by-Step Solution

1
Identify the primary pharmacological risks associated with continuous intravenous heparin therapy.
The major risks include systemic hemorrhage and a paradoxical immune response known as heparin-induced thrombocytopenia (HIT).
Understanding potential complications dictates which assessment data must be prioritized.
2
Evaluate the provided assessment and laboratory data against expected therapeutic ranges.
The aPTT of 68 seconds68\text{ seconds} is therapeutic. The vital signs are stable. Small ecchymoses are expected side effects. However, the platelet count has dropped by over 50%.
Differentiating between expected therapeutic effects and critical adverse reactions is required to identify the true risk.
3
Determine which finding necessitates immediate escalation to the registered nurse.
The severe drop in platelets indicates suspected HIT, meaning the heparin must be stopped immediately to prevent life-threatening thrombotic events.
Practical nurses must promptly recognize and report critical laboratory shifts that threaten client safety.

Key Concept

Recognition of Heparin-Induced Thrombocytopenia (HIT)
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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