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Zorluk: ZorPharmacological and Parenteral Therapies

A client is receiving a continuous intravenous infusion of unfractionated heparin for the treatment of a pulmonary embolism. The client reports a new onset of dull, constant lower back pain. Assessment reveals a blood pressure of 106/72 mmHg (decreased from a baseline of 138/84 mmHg) and a heart rate of 114 beats/minute. Which action should the nurse take first?

  1. A
    Administer a prescribed PRN analgesic to treat the client's lower back pain.
  2. B
    Obtain a STAT 12-lead electrocardiogram to evaluate the new onset of tachycardia.
  3. C
    Document the vital signs and reassess the client in 30 minutes.
  4. Stop the continuous intravenous infusion of unfractionated heparin immediately.Cevap

Cevap

Stop the continuous intravenous infusion of unfractionated heparin immediately.
The client is demonstrating signs of a retroperitoneal hemorrhage, a potentially fatal complication of heparin therapy. The new onset of lower back pain, combined with a significant drop in blood pressure and the presence of tachycardia, are hallmark indicators of internal bleeding. The nurse's first and most critical action is to stop the heparin infusion to prevent further blood loss before notifying the provider, drawing labs, or preparing an antidote.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a new onset of lower back pain, tachycardia, and a significant drop in blood pressure from baseline while receiving a high-risk anticoagulant.
Identifying changes in condition is the first step in clinical judgment.
2
Correlate the symptoms with potential adverse effects of the medication.
Lower back pain combined with signs of early hypovolemic shock (tachycardia, decreasing blood pressure) strongly indicates retroperitoneal bleeding, a severe complication of heparin therapy.
Understanding life-threatening adverse reactions directs the prioritization of care.
3
Determine the highest priority nursing action.
The immediate action must address the active cause of the hemorrhage by stopping the heparin infusion.
Removing the offending pharmacological agent is the most critical intervention to stabilize the client and prevent further deterioration.

Anahtar Kavram

Recognition and immediate management of severe hemorrhagic complications (retroperitoneal bleeding) associated with continuous intravenous anticoagulant therapy.
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Pharmacological and Parenteral Therapies

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