What should the nurse do if a patient on continuous heparin IV suddenly shows a blood pressure drop to 90/50 mmHg?

What should the nurse do if a patient on continuous heparin IV suddenly shows a blood pressure drop to 90/50 mmHg?

• A. Continue monitoring vital signs
• B. Alert the medical team
• C. Immediately stop the heparin infusion
• D. Assess for signs of anaphylaxis

Answer: (C)

When a patient on continuous heparin IV shows a sudden drop in blood pressure to 90/50 mmHg, the most appropriate action is to immediately stop the heparin infusion. This is crucial because a drop in blood pressure could indicate a potential complication from heparin therapy, such as heparin-induced thrombocytopenia (HIT) or bleeding, potentially leading to life-threatening situations. Stopping the infusion promptly addresses the risk of further anticoagulation that could exacerbate the patient’s condition. In such situations, monitoring vital signs and alerting the medical team are essential subsequent actions; however, the primary and immediate response should focus on the safety of the patient by halting heparin administration. Assessing for signs of anaphylaxis may also be important, but it does not take priority as the first step in response to the blood pressure change, especially since heparin's anticoagulant effects pose a more immediate risk.

When a patient on continuous heparin IV shows a sudden drop in blood pressure to 90/50 mmHg, the most appropriate action is to immediately stop the heparin infusion. This is crucial because a drop in blood pressure could indicate a potential complication from heparin therapy, such as heparin-induced thrombocytopenia (HIT) or bleeding, potentially leading to life-threatening situations. Stopping the infusion promptly addresses the risk of further anticoagulation that could exacerbate the patient’s condition.

In such situations, monitoring vital signs and alerting the medical team are essential subsequent actions; however, the primary and immediate response should focus on the safety of the patient by halting heparin administration. Assessing for signs of anaphylaxis may also be important, but it does not take priority as the first step in response to the blood pressure change, especially since heparin's anticoagulant effects pose a more immediate risk.