Question

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement?

a. Notify the HCP immediately.
b. Check the client's PTT level.
c. Explain this results from the medication.
d. Assess the client's vital signs.

Answer 1

The nurse should first assess the client's vital signs and then explain that bruising can result from the medication. If there is a concern for more significant bleeding or if vital signs are unstable, the healthcare provider should be notified immediately.

Step-by-step explanation:

The nurse should perform an immediate assessment before proceeding with other interventions. The appearance of small purple hemorrhaged areas on the abdomen where low molecular weight heparin (LMWH) was administered could indicate a possible complication such as bruising or more serious bleeding. The appropriate action would be:

1. Assess the client's vital signs to ensure they are stable, as changes can indicate a more serious systemic issue.
2. Explain to the client that this can result from the medication, as LMWH can cause local bruising at the injection site.
3. If vital signs are unstable or there is a concern for more significant bleeding, notify the healthcare provider (HCP) immediately.
4. Checking the client's PTT level is not usually necessary with LMWH as it has a predictable anticoagulant response and is not typically monitored unless specific circumstances arise.

Local bruising is a common side effect of subcutaneous injections of anticoagulants, yet any sign of systemic bleeding or hematoma formation warrants a more thorough assessment and possible escalation to the healthcare provider.