A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?
A.
Observe for bruising of the skin.
B.
Administer medications intramuscularly.
C.
Monitor vital signs every 4 hours
D.
Provide a diet low in protein.
The correct answer and Explanation is :
The correct answer is A. Observe for bruising of the skin.
Explanation:
Alteplase (recombinant tissue plasminogen activator) is a thrombolytic agent used to dissolve blood clots in the treatment of conditions such as myocardial infarction (heart attack). When a client is receiving alteplase, it is critical to monitor for signs of bleeding or bruising due to the drug’s mechanism of action. Alteplase works by converting plasminogen to plasmin, which then breaks down fibrin in the clot. While this is beneficial for resolving the clot, it also increases the risk of bleeding throughout the body.
Observation for bruising of the skin is crucial because bruising can be an early sign of bleeding complications. It indicates that bleeding might be occurring under the skin, which could be a result of the thrombolytic therapy. Prompt recognition of such symptoms allows for early intervention to prevent more severe bleeding complications.
Administering medications intramuscularly (Option B) is generally avoided in patients receiving thrombolytic therapy due to the increased risk of bleeding. Intramuscular injections can cause bleeding at the injection site, which is why intravenous routes or oral medications are preferred when possible.
Monitoring vital signs every 4 hours (Option C) is important but may not be frequent enough to detect early signs of bleeding complications. Typically, more frequent monitoring is required during and after thrombolytic therapy to detect any sudden changes in the patient’s condition that might indicate complications.
Providing a diet low in protein (Option D) is not a standard recommendation related to thrombolytic therapy. Protein intake does not directly impact the efficacy or safety of alteplase, so this action does not align with typical care considerations for patients undergoing this treatment.
Overall, observing for bruising of the skin is the most directly relevant action to include in the care plan for a client receiving alteplase, as it helps in early detection of potential bleeding issues.