Which of the following should the nurse do when providing care to a patient receiving Xigris?
1. discontinue infusion with signs of hemorrhage
2. monitor red blood cell count
3. monitor platelet count
4. measure strict intake and output
1
Rationale: Xigris is a recombinant form of activated protein C that exerts antithrombotic and anticoagulation effects by inhibiting clotting factor Va and VIIIa. It exerts anti-inflammatory effect by inhibiting mediators and the thrombin-induced inflammatory responses of the endothelium. This medication also possesses profibrinolytic and anti-inflammatory properties and helps to reduce mortality in patients with sepsis and evidence of multiple organ dysfunction syndrome. The major side effect of this medication is bleeding. The nurse should discontinue the infusion with any signs or evidence of hemorrhage. The patient's prothrombin time should be closely monitored. The red blood cell count and platelet count do not need to be monitored. The patient does not need to be on strict intake and output because of this medication.
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