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Difficulty: HardReduction of Risk Potential

A nurse is caring for a 65-year-old client who is receiving an intravenous infusion of alteplase (rtPA) for an acute ischemic stroke. Thirty minutes into the infusion, the client reports a sudden, severe headache, becomes intensely nauseous, and exhibits a new unilateral pupillary dilation. To reduce the risk of catastrophic neurological deterioration, arrange the following nursing actions in the correct priority order from first to last.

  1. 1Discontinue the intravenous alteplase infusion immediately.
  2. 2Assess airway patency, breathing, and hemodynamic stability.
  3. 3Notify the rapid response team and the neurologist.
  4. 4Transport the client for an emergent non-contrast head CT scan.
  5. 5Draw blood for a stat coagulation profile and type and screen.

Answer

The correct sequence is to first stop the alteplase infusion, then assess the airway and hemodynamics, notify the healthcare team, send the client for an emergent CT scan, and finally draw blood for coagulation studies.
The physiological integrity of the client is best preserved by immediately eliminating the source of harm (stopping alteplase). Once the immediate risk is mitigated, the nurse secures the airway and stabilizes hemodynamics. Following stabilization, communicating with the medical team allows for orders that direct diagnostic confirmation (CT scan) and subsequent supportive care preparation (drawing blood for coagulation factors).

Step-by-Step Solution

1
Discontinue the intravenous alteplase infusion immediately.
The delivery of the fibrinolytic agent is halted.
Symptoms such as sudden severe headache, nausea, and pupillary changes during alteplase administration strongly indicate hemorrhagic conversion. Stopping the drug minimizes further coagulopathy and limits expanding intracranial hemorrhage.
2
Assess airway patency, breathing, and hemodynamic stability.
Immediate life threats regarding oxygenation, ventilation, and perfusion are identified.
An expanding intracranial hemorrhage can cause rapid depression of the central nervous system, leading to loss of airway reflexes. This assessment determines if immediate intubation or cardiovascular support is required.
3
Notify the rapid response team and the neurologist.
Advanced medical support and targeted interventions are mobilized.
The provider must evaluate the client and order emergency diagnostics and pharmacological reversal agents.
4
Transport the client for an emergent non-contrast head CT scan.
The presence of intracranial bleeding is confirmed or ruled out.
A non-contrast CT is the gold standard for rapidly identifying acute hemorrhage, which dictates the subsequent medical or surgical management.
5
Draw blood for a stat coagulation profile and type and screen.
Laboratory data is obtained to guide blood product administration.
Preparing for the administration of cryoprecipitate, platelets, or antifibrinolytic agents requires baseline coagulation values and blood typing.

Key Concept

Prioritization of interventions for life-threatening complications of fibrinolytic therapy requires immediately removing the causative agent before assessing ABCs and escalating care.
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Reduction of Risk Potential

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