A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements from the patient warrants further assessment and intervention by the critical care nurse?
a. "My back is killing me!"
b. "There is blood on my toothbrush!"
c. "Look at the bruises on my arms!"
d. "My arm is bleeding where my IV is!"
A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not causes for concern. However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors, or both are administered.
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