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Difficulty: EasyReduction of Risk Potential

A practical nurse is collecting data on a client who is receiving continuous intravenous heparin therapy for a deep vein thrombosis. Which of the following findings indicate a potential complication and must be reported to the registered nurse immediately? (Select all that apply)

  1. Emesis that has a coffee-ground appearanceAnswer
  2. A platelet count of 60,000 /mm360,000 \text{ /mm}^3Answer
  3. Oozing of blood from the intravenous insertion siteAnswer
  4. D
    An activated partial thromboplastin time (aPTT) of 60 seconds60 \text{ seconds}
  5. E
    A resting heart rate of 76 beats/min76 \text{ beats/min} and a blood pressure of 122/78 mm Hg122/78 \text{ mm Hg}

Answer

The findings that must be reported immediately are coffee-ground emesis, a platelet count of 60,000 /mm360,000 \text{ /mm}^3, and oozing of blood from the intravenous site, as these all indicate active bleeding or a severe risk for hemorrhage.
Heparin is a high-alert anticoagulant that significantly increases the risk of hemorrhage. Coffee-ground emesis indicates upper gastrointestinal bleeding. A platelet count of 60,000 /mm360,000 \text{ /mm}^3 is critically low (thrombocytopenia) and predisposes the client to severe bleeding, possibly indicating heparin-induced thrombocytopenia (HIT). Oozing from the intravenous site is a direct sign of active bleeding. The practical nurse must immediately report these findings to the registered nurse for prompt intervention, which may include stopping the infusion or administering an antidote.

Step-by-Step Solution

1
Identify the medication and its primary risks.
The client is receiving continuous intravenous heparin, an anticoagulant that significantly increases the risk of bleeding.
Understanding the mechanism of the medication highlights what complications to look for during data collection.
2
Evaluate the clinical findings for signs of bleeding or shock.
Coffee-ground emesis and IV site oozing are direct signs of active bleeding. A critically low platelet count (60,000 /mm360,000 \text{ /mm}^3) predisposes the client to severe bleeding.
Active bleeding or critical thrombocytopenia requires immediate escalation to the registered nurse to prevent life-threatening hemorrhage.
3
Distinguish between expected therapeutic results and complications.
An aPTT of 60 seconds60 \text{ seconds} is an expected therapeutic response to heparin. The vital signs are completely normal.
Escalating expected or normal findings demonstrates a lack of understanding of the prescribed therapy and baseline stability.

Key Concept

Reduction of Risk Potential: Complications of Anticoagulant Therapy
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Topics

Reduction of Risk Potential

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