Nursing Prioritization Delegation Assignment Q 38
A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.
A. Use a lift sheet when moving and positioning the patient in bed.
B. Use an electric razor when shaving the patient each day.
C. Use a soft-bristled toothbrush or tooth sponge for oral care.
D. Use a rectal thermometer to obtain a more accurate body temperature.
E. Be sure the patient's footwear has a firm sole when the patient ambulates.
Correct Answers: A, B, C, and E.
All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Risk for bleeding may arise in any condition that disturbs the “close circuit” integrity of the circulatory system. Bleeding is the primary complication of anticoagulant therapy and is a risk of all anticoagulants even when maintained within the usual therapeutic ranges.
Option A: Educate the at-risk patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. Information about precautionary measures lessens the risk for bleeding.
Option B: Be careful when using sharp objects like scissors and knives. Use an electric razor for shaving (not razor blades). The patient needs to avoid situations that may cause tissue trauma and increase the risk for bleeding.
Option C: Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use of toothpicks and dental floss. This method providing oral hygiene reduces trauma to oral mucous membranes and the risk for bleeding from the gums.
Option D: While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). These invasive devices or medications may cause trauma to the mucous membranes that line the rectum or vagina.
Option E: Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a health care provider reduces the risk for complications from blood loss.