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Difficulty: Very hardPhysiological Adaptation

An 81-year-old client is receiving a continuous intravenous heparin infusion for a recent pulmonary embolism. During morning care, the client becomes restless, repeatedly asks where they are, and reports a new, dull ache in the lower back and flank. Current vital signs are blood pressure 104/64 mmHg (baseline 142/82 mmHg), heart rate 116 beats/minute, and respiratory rate 22 breaths/minute. Which action should the practical nurse (PN) take FIRST?

  1. Instruct the client to remain flat in bed and immediately alert the registered nurse of the assessment findings.Answer
  2. B
    Document the findings and plan to reassess the vital signs in 30 minutes since the systolic blood pressure remains above 100 mmHg.
  3. C
    Initiate the facility's delirium protocol and request a prescription for a urinalysis to check for a systemic infection.
  4. D
    Assist the client into a lateral decubitus position and apply a prescribed warm compress to the flank area to relieve the pain.

Answer

The correct action is to keep the client flat in bed and immediately alert the registered nurse of the assessment findings.
The client is exhibiting classic signs of a retroperitoneal hemorrhage (new flank pain) leading to early, compensatory hypovolemic shock (tachycardia, significant blood pressure drop from baseline, restlessness, and confusion due to decreased cerebral perfusion). Because the client is on a continuous heparin infusion, they are at extreme risk for severe bleeding. The practical nurse must keep the client flat to maintain venous return and brain perfusion, and immediately escalate this life-threatening emergency to the registered nurse for rapid collaborative intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation alongside their current high-risk medication therapy.
The client is on a heparin infusion and is presenting with new flank pain, which is a hallmark sign of retroperitoneal hemorrhage.
Anticoagulant therapy carries a high risk for internal bleeding, which must be ruled out whenever new, unexplained pain occurs in the back, flank, or abdomen.
2
Evaluate the vital signs and neurological status against the client's baseline.
The blood pressure has dropped significantly (from 142/82 to 104/64), the heart rate is elevated (116 bpm), and the client has new-onset confusion and restlessness.
These are classic signs of compensatory hypovolemic shock. The tachycardia attempts to maintain cardiac output, while the confusion indicates decreased oxygenation to the brain.
3
Determine the highest priority nursing intervention within the PN scope of practice.
The PN must recognize this as an acute circulation (ABC) emergency, keep the client flat to optimize venous return to the heart and brain, and urgently notify the RN.
Internal hemorrhage requires rapid medical intervention (stopping the heparin, administering fluids/blood products) that requires RN and provider action.

Key Concept

Recognizing early signs of retroperitoneal hemorrhage and compensatory hypovolemic shock in older adults receiving anticoagulant therapy.
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Physiological Adaptation

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