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Question

Difficulty: HardReduction of Risk Potential

A client being treated for a deep vein thrombosis is receiving a continuous intravenous heparin infusion. While the practical nurse is assisting the client with morning hygiene, the client suddenly complains of a severe, new-onset headache. The client's most recent activated partial thromboplastin time (aPTT) result is 118 seconds, and the normal control value is 30 seconds. Which of the following actions should the practical nurse take first?

  1. Immediately alert the supervising registered nurse about the client's symptom and laboratory valueAnswer
  2. B
    Administer the prescribed as-needed oral acetaminophen to treat the client's headache
  3. C
    Discontinue the continuous intravenous heparin infusion and prepare to administer protamine sulfate
  4. D
    Document the elevated laboratory result and reassess the client's neurological status in one hour

Answer

The practical nurse should immediately alert the supervising registered nurse about the client's symptom and the elevated aPTT result.
The client is presenting with a new symptom (severe headache) that, when combined with a critically elevated aPTT (118 seconds), strongly suggests a life-threatening complication such as an intracranial hemorrhage. The therapeutic range for aPTT is typically 1.5 to 2.5 times the control value (45 to 75 seconds). A value of 118 seconds places the client at extreme risk for spontaneous bleeding. The primary responsibility of the practical nurse in this scenario is to recognize the risk potential and immediately escalate the situation to the supervising registered nurse for prompt evaluation and intervention.

Step-by-Step Solution

1
Analyze the laboratory data
The aPTT of 118 seconds is significantly higher than the therapeutic range (which is usually 1.5 to 2.5 times the control of 30 seconds, or 45 to 75 seconds).
To determine if the client is at an increased risk for adverse effects from the heparin infusion.
2
Correlate the laboratory data with the clinical symptom
A severe, new-onset headache combined with a critically high aPTT indicates an extreme risk for spontaneous bleeding, specifically a potential intracranial hemorrhage.
To recognize the presence of a life-threatening complication requiring immediate intervention.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice
The situation requires immediate escalation to the registered nurse (RN) or healthcare provider.
The practical nurse must report critical findings and changes in condition to the RN for advanced assessment, collaborative management, and potential changes to the medical treatment plan.

Key Concept

Recognizing and Escalating Critical Laboratory Values and Complications
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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