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Zorluk: Çok zorReduction of Risk Potential

A practical nurse (PN) is reviewing the morning laboratory results for a client who was admitted 48 hours ago with a left deep vein thrombosis (DVT). The client has a prescription for a scheduled dose of subcutaneous heparin.

Laboratory TestCurrent ResultAdmission Baseline
Hemoglobin13.2 g/dL13.5 g/dL
White blood cells7,500/mm³7,200/mm³
Platelets95,000/mm³220,000/mm³
Potassium4.1 mEq/L4.0 mEq/L

During the morning data collection, the client reports new, sudden swelling and severe tenderness in the right leg. Based on these findings, which action is the priority for the PN?

  1. Withhold the scheduled heparin dose and immediately notify the registered nurse.Cevap
  2. B
    Administer the scheduled heparin to prevent further clot formation in the newly affected leg.
  3. C
    Perform a comprehensive neurovascular assessment to determine the extent of the new thrombosis.
  4. D
    Provide the prescribed PRN oral analgesic for the leg tenderness before administering the heparin.

Cevap

The correct action is to withhold the scheduled heparin dose and immediately notify the registered nurse.
The client is exhibiting classic signs of heparin-induced thrombocytopenia (HIT), a life-threatening complication characterized by a sudden drop in platelets (typically greater than 50% from baseline) and paradoxical new thrombus formation (evidenced by the new swelling in the right leg). The most critical action to reduce risk is to withhold any further heparin products immediately and alert the registered nurse so medical intervention can begin.

Adım Adım Çözüm

1
Analyze the laboratory data trends against the baseline.
The platelet count has dropped significantly from 220,000/mm³ to 95,000/mm³ (a greater than 50% decrease) over 48 hours.
Identifying critical shifts in laboratory values is essential for safe medication administration.
2
Correlate the laboratory findings with the pharmacological treatment.
A precipitous drop in platelets in a client receiving heparin therapy strongly suggests Heparin-Induced Thrombocytopenia (HIT).
HIT is a severe, immune-mediated adverse drug reaction.
3
Synthesize the laboratory data with the current clinical assessment.
HIT causes paradoxical widespread clotting, which explains the client's new, sudden swelling in the contralateral (right) leg despite anticoagulant therapy.
Connecting systemic signs to lab values confirms the clinical emergency.
4
Determine the priority nursing action within the practical nursing scope.
The PN must withhold the contraindicated medication and escalate the critical change in condition to the RN immediately.
Administering further heparin is life-threatening, and managing complex new complications requires RN collaboration.

Anahtar Kavram

Recognizing complications of anticoagulant therapy (Heparin-Induced Thrombocytopenia) and escalating critical laboratory values.
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Konular

Reduction of Risk Potential

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