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Difficulty: HardReduction of Risk Potential

A 74-year-old client is admitted to the progressive care unit with a large acute pulmonary embolism and is receiving a continuous intravenous (IV) heparin infusion. The nurse is creating a plan of care to monitor for and reduce the risk of potential physiological complications. Which of the following actions should the nurse include in the plan of care? Select all that apply.

  1. Establish a secondary peripheral intravenous access site for the administration of other prescribed intermittent medications.Answer
  2. Monitor the client for early physiological indicators of hemodynamic compromise, such as a narrowing pulse pressure and unexplained tachycardia.Answer
  3. Ensure that the specific antidote, protamine sulfate, is readily available on the unit.Answer
  4. D
    Place the client in a flat, supine position to optimize cerebral perfusion if they report a sudden increase in sharp chest pain.
  5. E
    Delegate the ongoing evaluation of the client's respiratory status and work of breathing to the unlicensed assistive personnel (UAP).
  6. F
    Attribute new-onset mild confusion or restlessness to the client's advanced age and the unfamiliar hospital environment.

Answer

The correct interventions are establishing a secondary IV access for other medications, monitoring for early signs of shock like a narrowing pulse pressure, and ensuring protamine sulfate is available on the unit.
Establishing a secondary peripheral IV line is necessary because continuous heparin infusions must run on a dedicated line to prevent inadvertent bolusing and medication incompatibilities. Monitoring for a narrowing pulse pressure and tachycardia allows for the early detection of obstructive shock, a life-threatening complication of a large pulmonary embolism. Ensuring protamine sulfate is available is a crucial safety measure to rapidly reverse heparin in the event of severe hemorrhage.

Step-by-Step Solution

1
Analyze the client's diagnosis and current treatments.
The client has a pulmonary embolism (high risk for hypoxemia and obstructive shock) and is on a continuous heparin infusion (high risk for hemorrhage and drug incompatibilities).
Identifying the primary physiological threats guides the selection of targeted risk reduction strategies.
2
Evaluate each intervention for its ability to safely mitigate these physiological risks.
Maintaining a dedicated heparin line, securing the antidote, and closely monitoring for early shock indicators (tachycardia, narrowing pulse pressure) directly reduce the risk of mortality and medication errors.
These actions prioritize airway, breathing, circulation, and medication safety.
3
Identify and eliminate contraindicated or unsafe actions.
Placing the dyspneic client supine, delegating complex nursing assessments to a UAP, and dismissing altered mental status as normal aging are dangerous missteps.
A supine position impairs breathing, UAPs cannot perform clinical evaluations, and confusion indicates severe, acute hypoxemia.

Key Concept

Risk reduction in clients with pulmonary embolism focuses on maintaining oxygenation (high-Fowler's position), preventing hemorrhage (dedicated heparin line, readily available antidotes), and early detection of hemodynamic compromise or hypoxemia (recognizing subtle vital sign changes and altered mental status).
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Reduction of Risk Potential

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