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Difficulty: HardReduction of Risk Potential

A nurse is caring for a client who is receiving a continuous intravenous infusion of alteplase for an acute ischemic stroke. During the infusion, the client suddenly reports a severe, bursting headache, exhibits extreme restlessness, and the blood pressure increases to 198/112 mm Hg. Which action should the nurse take first to reduce the client's risk for life-threatening complications?

  1. A
    Lower the head of the bed to a flat, supine position to ensure adequate cerebral perfusion to the ischemic penumbra.
  2. B
    Obtain an arterial blood gas (ABG) sample to evaluate if acute hypercapnia is causing the sudden hypertension and restlessness.
  3. C
    Auscultate heart and lung sounds fully before administering prescribed PRN intravenous antihypertensive medications.
  4. Discontinue the alteplase infusion immediately and prepare the client for an emergency noncontrast head CT scan.Answer

Answer

The correct action is to immediately discontinue the alteplase infusion and prepare the client for an emergency CT scan.
The client is exhibiting classic signs of hemorrhagic conversion (intracranial bleeding), which is the most severe and life-threatening complication of thrombolytic therapy. A sudden, severe headache, decreased level of consciousness or restlessness, and acute severe hypertension represent an acute neurological emergency. The absolute highest priority to reduce the risk of death or permanent disability is to immediately stop the infusion of the fibrinolytic agent.

Step-by-Step Solution

1
Analyze the client's sudden onset of a severe headache, extreme restlessness, and severe hypertension (198/112 mm Hg) during alteplase therapy.
Recognize these findings as classic clinical indicators of hemorrhagic conversion (intracranial bleeding).
Alteplase is a potent thrombolytic that carries a high risk of bleeding; acute neurological deterioration mandates immediate suspicion of hemorrhage.
2
Determine the highest priority nursing intervention to mitigate physiological risk.
Identify that the thrombolytic infusion must be stopped immediately.
Continuing the alteplase infusion will exacerbate active intracranial bleeding, potentially leading to fatal brain herniation.
3
Anticipate the immediate subsequent medical requirement.
Prepare the client for a stat noncontrast head CT scan.
A CT scan is the definitive diagnostic tool to confirm intracranial hemorrhage and guide subsequent reversal therapies.

Key Concept

Thrombolytic Therapy Complications and Hemorrhagic Conversion
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Topics

Reduction of Risk Potential

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