A client being treated for a deep vein thrombosis is receiving a continuous intravenous heparin infusion. While the practical nurse is assisting the client with morning hygiene, the client suddenly complains of a severe, new-onset headache. The client's most recent activated partial thromboplastin time (aPTT) result is 118 seconds, and the normal control value is 30 seconds. Which of the following actions should the practical nurse take first?
- Immediately alert the supervising registered nurse about the client's symptom and laboratory valueCevap
- BAdminister the prescribed as-needed oral acetaminophen to treat the client's headache
- CDiscontinue the continuous intravenous heparin infusion and prepare to administer protamine sulfate
- DDocument the elevated laboratory result and reassess the client's neurological status in one hour
Cevap
The practical nurse should immediately alert the supervising registered nurse about the client's symptom and the elevated aPTT result.
The client is presenting with a new symptom (severe headache) that, when combined with a critically elevated aPTT (118 seconds), strongly suggests a life-threatening complication such as an intracranial hemorrhage. The therapeutic range for aPTT is typically 1.5 to 2.5 times the control value (45 to 75 seconds). A value of 118 seconds places the client at extreme risk for spontaneous bleeding. The primary responsibility of the practical nurse in this scenario is to recognize the risk potential and immediately escalate the situation to the supervising registered nurse for prompt evaluation and intervention.
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Anahtar Kavram
Recognizing and Escalating Critical Laboratory Values and Complications
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