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Difficulty: Very hardReduction of Risk Potential

A 6868-year-old client is admitted to the medical-surgical unit with a deep vein thrombosis and is receiving a continuous intravenous heparin infusion. The practical nurse is reviewing the morning laboratory results and performing a routine assessment. The client's activated partial thromboplastin time (aPTT) is 118118 seconds (control 3232 seconds). During the assessment, the client reports a new, persistent headache. Vital signs are heart rate 112112 bpm, blood pressure 94/5894/58 mm Hg (baseline 132/78132/78 mm Hg), and respirations 2020/min. What is the most appropriate next action for the practical nurse to take?

  1. Instruct the client to remain strictly in bed and urgently communicate the clinical findings to the supervising registered nurse.Answer
  2. B
    Decrease the heparin infusion rate according to the facility weight-based nomogram and recheck the aPTT in six hours.
  3. C
    Offer the client a prescribed as-needed analgesic for the headache and dim the lights in the room to promote comfort.
  4. D
    Record the vital signs in the electronic health record and plan to reassess the blood pressure in one hour.

Answer

Instruct the client to remain strictly in bed and urgently communicate the clinical findings to the supervising registered nurse.
The correct answer directly addresses the immediate risk of severe internal hemorrhage while remaining within the appropriate scope of practice. An aPTT of 118118 seconds is critically elevated. Combined with a new headache, tachycardia, and a precipitous drop in blood pressure, these findings strongly suggest active internal bleeding (such as intracranial or gastrointestinal hemorrhage). The practical nurse must prioritize client safety by instituting bed rest and immediately escalating these critical findings to the registered nurse for urgent medical intervention.

Step-by-Step Solution

1
Evaluate the aPTT laboratory result against the provided normal control value.
The aPTT of 118118 seconds is recognized as critically high, well beyond the standard therapeutic range of 1.51.5 to 2.52.5 times the control (4848 to 8080 seconds).
Identifying critical values is the first step in recognizing severe physiological risk, specifically spontaneous hemorrhage.
2
Correlate the critical coagulation result with the client's vital signs and subjective symptoms.
The combination of a critically high aPTT, a new persistent headache, tachycardia (112112 bpm), and a significant drop in blood pressure (94/5894/58 mm Hg) strongly points to active internal bleeding, potentially intracranial.
Synthesizing multiple clinical data points allows for the recognition of acute clinical deterioration and shock.
3
Determine the safest and most appropriate intervention within the practical nurse scope of practice.
The nurse identifies that protecting the client from falls (strict bed rest) and immediately escalating the findings to the registered nurse is required.
Practical nurses must independently recognize life-threatening complications but must collaborate with or delegate to the RN for the management of continuous high-risk infusions and complex medical interventions.

Key Concept

Early recognition of internal hemorrhage and escalation within the practical nursing scope of practice.
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Reduction of Risk Potential

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