A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats per minute and a blood pressure of 110/72 mm Hg. The patient's fingertips are purplish in color
A stat CBC shows a platelet count of less than 100,000 mm3 . The nurse will: a. administer oxygen and notify the provid-er.
b. discontinue the heparin and notify the provider.
c. request an order for protamine sulfate.
d. request an order for vitamin K (phytona-dione).
B
This patient is showing signs of heparin-induced thrombocytopenia, so the heparin should be discontinued immediately and the provider should be notified. The purplish color of the finger-tips is caused by thrombosis, not hypoxia, so oxygen is not indicated. This patient may need con-tinued anticoagulation therapy, so a request for protamine sulfate is not correct. Heparin is not a vitamin K inhibitor.
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