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Difficulty: HardPharmacological Therapies

While monitoring an older adult client who is being treated with a continuous intravenous heparin infusion for a pulmonary embolism, a practical nurse (PN) reviews the trend of the client's vital signs. Over the past four hours, the client's heart rate has climbed from 78 bpm78\text{ bpm} to 112 bpm112\text{ bpm}, and the blood pressure has trended downward from 134/82 mmHg134/82\text{ mmHg} to 104/68 mmHg104/68\text{ mmHg}. The client currently reports feeling faint. What is the priority action for the PN?

  1. Escalate the clinical findings immediately to the primary registered nurse.Answer
  2. B
    Record the data in the client's chart and reassess the blood pressure in one hour.
  3. C
    Adjust the heparin infusion rate downward according to the facility's titration protocol.
  4. D
    Assist the client to a seated position at the edge of the bed to manage the faintness.

Answer

The priority action is to escalate the clinical findings immediately to the primary registered nurse.
The client's presentation of a climbing heart rate, dropping blood pressure, and faintness while receiving a continuous heparin infusion strongly points to internal hemorrhage and early hypovolemic shock. Because the client is experiencing a critical, life-threatening adverse effect that requires complex assessment and potential medical intervention (such as stopping the infusion or administering fluids), the practical nurse must prioritize immediately notifying the registered nurse to initiate a rapid response.

Step-by-Step Solution

1
Analyze the client's medication and current symptoms.
The client is on a continuous heparin infusion (high risk for bleeding) and presents with new-onset tachycardia, decreasing blood pressure, and faintness.
Identifying the relationship between the pharmacological therapy and new physical symptoms is essential for recognizing adverse drug events.
2
Interpret the vital sign trends and prioritize care.
The shift from normal baseline vital signs to tachycardia and borderline hypotension indicates early hypovolemic shock, likely due to internal hemorrhage.
Early recognition of shock requires prioritizing Circulation and immediate medical intervention to prevent cardiovascular collapse.
3
Determine the appropriate action within the practical nurse's scope of practice.
The PN must immediately notify the registered nurse rather than independently altering intravenous medications or delaying care.
Managing a hemodynamically unstable client and titrating intravenous anticoagulants fall outside the PN scope of practice.

Key Concept

Monitoring for adverse effects of anticoagulant therapy and adhering to the practical nurse scope of practice.
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Pharmacological Therapies

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