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Difficulty: Very hardPharmacological Therapies

A practical nurse (PN) is caring for a client being treated for a pulmonary embolism. The client is receiving a continuous intravenous heparin infusion. The health care provider prescribes oral warfarin 5 mg5\text{ mg} daily to begin today. The client's morning laboratory results show an activated partial thromboplastin time (aPTT) of 115 seconds115\text{ seconds} (control: 30 seconds30\text{ seconds}) and an International Normalized Ratio (INR) of 1.11.1. The PN assesses the client and notes a blood pressure of 98/62 mm Hg98/62\text{ mm Hg} (baseline 136/84 mm Hg136/84\text{ mm Hg}) and a heart rate of 108 bpm108\text{ bpm} (baseline 74 bpm74\text{ bpm}).

Which of the following is the priority action for the practical nurse to take?

  1. A
    Stop the intravenous heparin infusion immediately, administer the oral warfarin, and initiate strict bleeding precautions.
  2. B
    Administer the oral warfarin since the INR is subtherapeutic, and continue to monitor the client's vital signs routinely.
  3. C
    Withhold the oral warfarin due to the elevated aPTT, document the vital signs, and reassess the client in one hour.
  4. Notify the registered nurse immediately of the assessment findings and laboratory results, and remain with the client.Answer

Answer

The correct action is to immediately notify the registered nurse of the assessment findings and laboratory results while remaining with the client.
The correct answer involves immediately notifying the registered nurse. The client's aPTT is critically elevated at 115 seconds (therapeutic range is generally 1.5 to 2.5 times the control of 30 seconds), indicating profound anticoagulation. Combined with the sudden drop in blood pressure and increase in heart rate, the client is exhibiting early signs of internal hemorrhage. Because managing a circulatory crisis and altering a continuous intravenous infusion of a high-alert medication are outside the practical nurse's scope of practice, the immediate priority is to escalate the situation to the RN while ensuring client safety.

Step-by-Step Solution

1
Analyze the laboratory values to determine the client's coagulation status.
The aPTT of 115 seconds is critically elevated (therapeutic range is 45-75 seconds), indicating a severe risk for bleeding. The INR of 1.1 is expected because oral warfarin therapy is just being initiated.
Heparin therapy is monitored via aPTT, and warfarin therapy is monitored via INR. Recognizing toxic levels is essential for medication safety.
2
Evaluate the client's vital signs compared to their baseline.
The client has developed new-onset tachycardia (HR 108 bpm) and relative hypotension (BP 98/62 mm Hg).
In the context of a critically high aPTT, these borderline vital signs are early physiological indicators of active internal hemorrhage.
3
Determine the priority action within the practical nurse's scope of practice.
The PN must immediately escalate the findings to the registered nurse (RN).
The client is experiencing a circulatory emergency. Intervening on a continuous high-alert intravenous medication like heparin falls outside the PN scope of practice, making immediate RN notification the only safe priority action.

Key Concept

Pharmacological Therapies, Adverse Effects, and Scope of Practice
Estimated Time:1m 30s
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Topics

Pharmacological Therapies

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