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Zorluk: ZorReduction of Risk Potential

A practical nurse is collecting data from a client who was admitted with a pulmonary embolism and is currently receiving a continuous intravenous heparin infusion. Which of the following findings indicate a high risk for potential complications and require immediate notification of the supervising registered nurse? Select all that apply.

  1. A platelet count of 88,000/mm388,000/\text{mm}^3Cevap
  2. A resting heart rate of 115 beats per minute accompanied by a blood pressure of 98/62 mm HgCevap
  3. The client reporting the sudden onset of a severe headacheCevap
  4. D
    An activated partial thromboplastin time (aPTT) result of 64 seconds
  5. E
    A positive D-dimer blood test result
  6. F
    A pulse oximetry reading of 94% while receiving 2 liters of oxygen per minute via nasal cannula

Cevap

The correct findings that require immediate escalation are a platelet count of 88,000/mm388,000/\text{mm}^3, a resting heart rate of 115 beats per minute with a blood pressure of 98/62 mm Hg, and the sudden onset of a severe headache.
Clients on continuous intravenous heparin are at significant risk for hemorrhage and heparin-induced thrombocytopenia (HIT). A sudden, severe headache is a cardinal sign of intracranial bleeding. Tachycardia combined with borderline hypotension suggests early hypovolemic shock from internal blood loss. A platelet count of 88,000/mm388,000/\text{mm}^3 falls well below the normal range, indicating potential HIT, which can cause paradoxical life-threatening thrombosis. All three findings require immediate cessation of therapy and rapid RN/provider intervention.

Adım Adım Çözüm

1
Analyze the client's current clinical situation and treatment.
The client has a pulmonary embolism and is on continuous IV heparin, placing them at high risk for bleeding complications and heparin-induced thrombocytopenia (HIT).
Understanding the high-risk therapy guides the identification of life-threatening adverse effects.
2
Evaluate the laboratory values against therapeutic expectations.
A platelet count of 88,000/mm388,000/\text{mm}^3 is critically low (normal 150,000−400,000/mm3150,000-400,000/\text{mm}^3) indicating potential HIT. An aPTT of 64 seconds is therapeutic (1.5-2.5 times the control of 25-35 seconds). A positive D-dimer is expected given the PE diagnosis.
Differentiating between expected therapeutic effects and critical laboratory abnormalities is essential for safe care.
3
Assess the vital signs and subjective data for signs of shock or hemorrhage.
Tachycardia (115 bpm) with borderline hypotension (98/62 mm Hg) suggests early hemorrhagic shock. A sudden severe headache indicates possible intracranial bleeding. An SpO2 of 94% on 2L O2 is a stable finding for this respiratory condition.
Recognizing subtle signs of internal bleeding ensures timely escalation before hemodynamic collapse occurs.

Anahtar Kavram

Continuous heparin therapy requires vigilant monitoring for adverse effects, specifically systemic bleeding, intracranial hemorrhage (indicated by severe headache), and heparin-induced thrombocytopenia (indicated by a profound drop in platelets).
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Reduction of Risk Potential

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