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Zorluk: Çok zorReduction of Risk Potential

A practical nurse is reviewing the electronic health record of an adult client who has been receiving a continuous intravenous heparin infusion for a pulmonary embolism for the past four days. The practical nurse notes the following morning laboratory results:

- Activated partial thromboplastin time (aPTT): 6262 seconds (Control: 3030 seconds)
- Hemoglobin: 13.2 g/dL13.2 \text{ g/dL}
- Platelet count: 105,000 /mm3105,000 \text{ /mm}^3 (Baseline on admission: 240,000 /mm3240,000 \text{ /mm}^3)

During the morning assessment, the client's vital signs are within expected parameters, but the client reports a new onset of coldness, intense pain, and tingling in the right foot. Which action should the practical nurse take first?

  1. Immediately notify the registered nurse of the assessment findings and laboratory trends.Cevap
  2. B
    Assess the client's bilateral pedal pulses using a Doppler ultrasound device.
  3. C
    Stop the continuous intravenous heparin infusion to prevent further vascular complications.
  4. D
    Document the activated partial thromboplastin time as therapeutic and continue routine monitoring.

Cevap

The correct action is to immediately notify the registered nurse of the assessment findings and laboratory trends.
The client is exhibiting classic signs of Heparin-Induced Thrombocytopenia (HIT), evidenced by a platelet count drop of greater than 50%50\% from baseline, combined with symptoms of a new arterial thrombosis (coldness, intense pain, and tingling in the foot). This is a life-threatening medical emergency. The practical nurse's highest priority is to immediately communicate these critical findings to the registered nurse so that the heparin infusion can be safely discontinued and alternative limb-saving treatments initiated.

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1
Analyze the laboratory values by comparing the current morning results to the admission baseline.
The aPTT is therapeutic (6262 seconds is approximately 22 times the control of 3030 seconds). However, the platelet count has decreased by more than 50%50\% from the baseline (240,000240,000 to 105,000 /mm3105,000 \text{ /mm}^3).
A drop in platelets of >50%>50\% in a client receiving heparin therapy is a hallmark clinical indicator of Heparin-Induced Thrombocytopenia (HIT).
2
Evaluate the significance of the client's new physical assessment findings.
The client reports coldness, intense pain, and tingling in the right foot.
These symptoms strongly indicate acute arterial occlusion (thrombosis). In the context of a dropping platelet count on heparin therapy, this represents a paradoxical, life-threatening complication of HIT.
3
Determine the scope of practice and highest priority intervention for the practical nurse.
The practical nurse must immediately escalate these critical assessment and laboratory findings to the registered nurse.
The client is experiencing a medical emergency requiring rapid collaborative intervention (stopping the heparin and initiating non-heparin anticoagulants). The practical nurse cannot independently alter the IV drip, and further assessment would dangerously delay care.

Anahtar Kavram

Reduction of Risk Potential: Recognizing and escalating Heparin-Induced Thrombocytopenia (HIT) and arterial occlusion.
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Konular

Reduction of Risk Potential

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