Question

Mr. H, 68 years old, has had a right-sided stroke. He was admitted to the telemetry unit 2 days ago and he has been on heparin therapy. The latest documentation in the nursing notes shows: Hand grips R stronger than L, speech slurred, BP 166/102. The orders in the nursing care Kardex include the following:

VS q4h I & O

Neuro checks q4h

Up in chair today

O2 @ 2 L/min/NP

Hospital day: #3

IV: 500 mL: D5W with heparin 10,000

units infuse at 1000 units/hr

Foley (¸) care bid

ROM to left upper and lower extremities

Serum K+, Na+ & CBC today

PTT daily

Diet: Dysphagia (to be determined after

swallow evaluation)

Swallowing precautions

Routine med:

Docusate sodium 20 mg (5 mL) po

bid

Nimodipine 20 mg po tid

Mr. H’s laboratory data are called to the unit. The results are as follows: PTT 250 sec (control 38 sec), K+ 3.5 mEq, Na+ 145 mEq, Hgb 11.4 g/dL, Hct 34%, platelets 110,000/mm3Mr. H’s laboratory data are called to the unit. The results are as follows: PTT 250 sec (control 38 sec), K+ 3.5 mEq, Na+ 145 mEq, Hgb 11.4 g/dL, Hct 34%, platelets 110,000/mm3

1.     Based on Mr. H’s laboratory data, identify and write the priority problem?

Answer 1

1. Based on Mr. H 's laboratory data , the priority problem is PTT = 250 sec due to excessive heparin therapy ,which further lead to excessive bleeding because of which his Hb= 11.4 g/dl and Hct = 34% decreased below normal range .