A nurse is caring for a client who is receiving a continuous intravenous heparin infusion for the treatment of a pulmonary embolism. The client suddenly reports the onset of a new, severe headache. The nurse reviews the most recent laboratory results:
| Laboratory Test | Client Result | Reference / Control |
|---|---|---|
| aPTT | 120 seconds | Control: 30 seconds |
| pH | 7.42 | 7.35 - 7.45 |
| PaCO2 | 38 mmHg | 35 - 45 mmHg |
| PaO2 | 94 mmHg | 80 - 100 mmHg |
| HCO3 | 24 mEq/L | 22 - 26 mEq/L |
Which of the following is the priority nursing action to reduce the client's risk for life-threatening complications?
- Stop the continuous heparin infusion immediately and perform a focused neurological assessment.Answer
- BAdminister the prescribed as-needed acetaminophen to treat the headache.
- CLower the head of the bed to a flat, supine position to promote cerebral perfusion.
- DInitiate supplemental oxygen therapy based on the arterial blood gas results.
Answer
The correct action is to stop the continuous heparin infusion immediately and perform a focused neurological assessment.
The client is exhibiting signs of a potential intracranial hemorrhage, a life-threatening complication of heparin toxicity. An aPTT of 120 seconds is significantly above the therapeutic range, placing the client at severe risk for spontaneous bleeding. The sudden, severe headache is a hallmark neurological symptom of an intracranial bleed. The absolute priority is to halt the anticoagulant infusion to prevent further hemorrhage and immediately assess the client's neurological status.
Step-by-Step Solution
Key Concept
Recognizing complications of anticoagulant therapy and prioritizing immediate risk reduction.