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Difficulty: MediumReduction of Risk Potential

While monitoring a client admitted with a right leg deep vein thrombosis (DVT), a practical nurse (PN) reviews the client's response to a continuous intravenous heparin infusion. Which assessment findings indicate a high risk for life-threatening complications and require immediate escalation to the registered nurse (RN)? Select all that apply.

  1. A platelet count that decreases from 230,000/mm³ to 90,000/mm³Answer
  2. The client reports a sudden onset of sharp chest pain and difficulty breathingAnswer
  3. A heart rate of 118 beats per minute and a blood pressure of 88/54 mm HgAnswer
  4. D
    An activated partial thromboplastin time (aPTT) of 60 seconds when the baseline control is 30 seconds
  5. E
    The client's right calf is warm, slightly red, and swollen compared to the left leg

Answer

The correct findings to escalate are the significant drop in platelets, the sudden onset of chest pain and difficulty breathing, and the tachycardia combined with hypotension.
The correct findings to escalate involve recognizing signs of severe complications related to both the underlying disease and the treatment. A significant decrease in platelets strongly suggests heparin-induced thrombocytopenia (HIT). Sudden chest pain and difficulty breathing are classic indicators that the DVT may have dislodged and caused a pulmonary embolism. Furthermore, tachycardia and hypotension in a client on anticoagulants indicate potential internal hemorrhage or shock. All of these require emergency RN and provider intervention.

Step-by-Step Solution

1
Evaluate the current laboratory values, specifically the platelet count.
The platelet count dropped significantly to 90,000/mm³.
A drop below 150,000/mm³ during heparin therapy indicates heparin-induced thrombocytopenia (HIT).
2
Assess the client's respiratory and cardiovascular status.
Sudden chest pain, dyspnea, tachycardia, and hypotension are present.
These are classic signs of life-threatening complications such as pulmonary embolism and hemorrhagic shock.
3
Review the activated partial thromboplastin time (aPTT) results.
The aPTT is 60 seconds (2 times the control of 30 seconds).
This is a therapeutic value for continuous heparin infusion, demonstrating the treatment is effective and safe.
4
Assess the localized signs of the deep vein thrombosis (DVT).
The right calf remains warm, red, and swollen.
These are expected baseline findings for a DVT and do not indicate a new emergency.

Key Concept

Identification of critical complications during anticoagulant therapy
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Topics

Reduction of Risk Potential

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