An older adult client is receiving a continuous intravenous infusion of unfractionated heparin for the treatment of a deep vein thrombosis. The client's most recent activated partial thromboplastin time (aPTT) is 118 seconds. During an assessment, the client reports a sudden onset of severe, localized lumbar back pain. The nurse notes a heart rate of 124 bpm, a blood pressure of 84/48 mmHg, and pale, diaphoretic skin. Which action should the nurse take first?
- Stop the continuous heparin infusion immediately and prepare to administer intravenous protamine sulfate.Answer
- BAdminister a rapid bolus of 0.9% sodium chloride through the heparin infusion line to correct the hypotension.
- CTitrate the continuous heparin infusion down by 50% according to the facility nomogram and draw a stat aPTT.
- DAdminister the prescribed intravenous opioid analgesic for the lumbar pain and reassess vital signs in 15 minutes.
Answer
The immediate priority is to stop the continuous heparin infusion and prepare to administer the antidote, intravenous protamine sulfate.
The client's presentation of sudden severe lumbar pain, hypotension, and tachycardia in the presence of a highly supratherapeutic aPTT (118 seconds) is the classic clinical triad for a retroperitoneal hemorrhage. Because the client is in active hypovolemic shock secondary to heparin toxicity, the absolute highest priority is to immediately stop the offending parenteral therapy (the heparin infusion) and prepare the specific pharmacological antidote, protamine sulfate, to reverse the anticoagulation.
Step-by-Step Solution
Key Concept
Recognizing severe parenteral drug toxicity (retroperitoneal hemorrhage from heparin) and prioritizing immediate cessation of the infusion alongside antidote administration.