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Difficulty: Very hardPharmacological Therapies

An older adult client is 24 hours24\text{ hours} postoperative following an open cholecystectomy. The client is prescribed scheduled subcutaneous dalteparin for venous thromboembolism prophylaxis. Morning laboratory results reveal a hemoglobin decrease from 14.1 g/dL14.1\text{ g/dL} (141 g/L141\text{ g/L}) to 10.2 g/dL10.2\text{ g/dL} (102 g/L102\text{ g/L}). During morning rounds, the client appears restless. The automated vital signs are: temperature 98.6∘F98.6^\circ\text{F} (37.0∘C37.0^\circ\text{C}), heart rate 116 beats/min116\text{ beats/min}, respiratory rate 22 breaths/min22\text{ breaths/min}, and blood pressure 98/62 mmHg98/62\text{ mmHg}. The registered nurse (RN) directs the practical nurse to administer the scheduled dalteparin. Which action should the practical nurse take?

  1. Withhold the dalteparin and immediately notify the registered nurse of the assessment findings and laboratory trends.Answer
  2. B
    Administer the dalteparin as delegated, ensuring two distinct client identifiers are checked prior to injection.
  3. C
    Coach the client through deep breathing exercises to manage the restlessness before administering the medication.
  4. D
    Document the hemoglobin value and administer the dalteparin, as the level has not reached the critical threshold for transfusion.

Answer

The practical nurse must withhold the scheduled dalteparin and immediately report the vital signs and hemoglobin drop to the registered nurse.
The correct action is to withhold the dalteparin and notify the RN. The combination of a sudden hemoglobin drop, tachycardia, borderline hypotension, and new-onset restlessness are classic early signs of hypovolemic shock secondary to internal bleeding. Administering an anticoagulant in this physiological state is extremely dangerous. The practical nurse must advocate for the client's safety by utilizing clinical judgment to withhold the dose and rapidly escalating the condition.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client presents with a newly elevated heart rate, borderline low blood pressure, and restlessness.
These findings are classic early compensatory mechanisms indicating hypovolemic shock.
2
Correlate the clinical presentation with the diagnostic laboratory data.
The hemoglobin has dropped significantly by nearly 4 g/dL4\text{ g/dL} within a 24-hour24\text{-hour} postoperative window.
A rapid decrease in hemoglobin combined with shock symptoms strongly confirms the likelihood of active internal hemorrhage.
3
Evaluate the prescribed pharmacological therapy against the client's acute physiological status.
Dalteparin is a low molecular weight heparin (anticoagulant).
Administering any anticoagulant to a client experiencing active internal bleeding will exacerbate the hemorrhage and further compromise circulation.
4
Determine the appropriate nursing action within the practical nurse scope of practice.
The practical nurse must withhold the medication and immediately escalate the clinical findings to the RN.
The practical nurse is responsible for ensuring medication safety and communicating critical physiological changes that require RN or provider intervention.

Key Concept

Safe medication administration requires evaluating physiological status; anticoagulants are contraindicated during active internal hemorrhage.
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Pharmacological Therapies

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