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Zorluk: ZorReduction of Risk Potential

A practical nurse is caring for a client who is receiving a continuous intravenous heparin infusion for a deep vein thrombosis. The client's baseline vital signs at the start of the shift were: heart rate 74/min and blood pressure 128/78 mm Hg. The nurse notes the current vital signs are: heart rate 114/min and blood pressure 102/64 mm Hg. Morning laboratory results indicate an activated partial thromboplastin time (aPTT) of 68 seconds and a hemoglobin level of 10.8 g/dL, which is a decrease from 13.2 g/dL the previous day. The client also reports a new, continuous, dull ache in the lower back. Which action should the nurse take first?

  1. A
    Administer the prescribed PRN oral acetaminophen for the reported back pain.
  2. B
    Document the findings in the electronic health record as the aPTT is within the therapeutic range.
  3. Notify the registered nurse immediately regarding the assessment findings.Cevap
  4. D
    Perform deep palpation of the client's lumbar region to assess the severity of the pain.

Cevap

The correct action is to notify the registered nurse immediately regarding the assessment findings.
The client is exhibiting classic signs of a retroperitoneal bleed, a severe complication of anticoagulant therapy. The combination of new-onset lower back pain (referred pain from blood pooling), tachycardia, mild hypotension, and a significant drop in hemoglobin indicates internal hemorrhage. Even though the aPTT is in the expected therapeutic range, bleeding can still occur. The practical nurse must immediately escalate these findings to the registered nurse to initiate rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's vital signs and physical complaints.
The client exhibits new-onset tachycardia, a downward trend in blood pressure, and a new dull ache in the lower back.
To identify any acute deviations from baseline that could indicate a complication of therapy.
2
Correlate the physical assessment findings with the laboratory results and current medications.
The client is on a high-alert anticoagulant (heparin) and has experienced a significant drop in hemoglobin (2.4 g/dL decrease) over 24 hours.
To recognize physiological patterns indicating adverse effects, such as internal bleeding.
3
Synthesize the collected data to identify the specific potential risk.
The combination of back pain, dropping hemoglobin, and early signs of shock strongly suggests a retroperitoneal hemorrhage.
Retroperitoneal bleeding is a known, life-threatening complication of systemic anticoagulation that often presents with insidious flank or back pain.
4
Determine the appropriate scope of practice and priority nursing action.
The practical nurse must immediately escalate these critical findings to the registered nurse.
Life-threatening complications require immediate RN assessment and provider intervention to stop the bleeding and stabilize the client.

Anahtar Kavram

Early recognition and escalation of anticoagulant-induced hemorrhage
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Konular

Reduction of Risk Potential

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