- Begin therapy as soon as possible after the onset of symptoms.Myocardial Infarction:
- Monitor vital signs, including temperature, continuously for myocardial infarction and at least every 4 hr during therapy for other indications. Do not use lower extremities to monitor BP. Notify health care professional if systolic BP >180 mm Hg or diastolic BP >110 mm Hg. Thrombolytic therapy should not be given if hypertension is uncontrolled. Inform health care professional if hypotension occurs. Hypotension may result from the drug, hemorrhage, or cardiogenic shock.
- Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15–30 min during the next 8 hr, and at least every 4 hr for the duration of therapy. Frank bleeding may occur from sites of invasive procedures or from body orifices. Internal bleeding may also occur (decreased neurologic status; abdominal pain with coffee-grounds emesis or black, tarry stools; hematuria; joint pain). If uncontrolled bleeding occurs, stop medication and notify health care professional immediately.
- Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform health care professional promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
- Assess neurologic status throughout therapy. Altered sensorium or neurologic changes may be indicative of intracranial bleeding.
- Monitor ECG continuously. Notify health care professional if significant arrhythmias occur. IV lidocaine or procainamide (Pronestyl) may be ordered prophylactically. Monitor cardiac enzymes. Radionuclide myocardial scanning and/or coronary angiography may be ordered 7–10 days after therapy to monitor effectiveness of therapy.Acute Ischemic Stroke:
- Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as directed. Notify health care professional if chest pain is unrelieved or recurs.
- Monitor heart sounds and breath sounds frequently. Inform health care professional if signs of HF occur (rales/crackles, dyspnea, S3 heart sound, jugular venous distention, relieved CVP).
- Assess neurologic status. Determine time of onset of stroke symptoms. Alteplase must be administered within 3–4.5 hr of onset (within 3 hrs in patients older than 80 years, those taking oral anticoagulants, those with a baseline National Institutes of Health Stroke Scale score 25, or those with both a history of stroke and diabetes).Pulmonary Embolism:
- Monitor pulse, BP, hemodynamics, and respiratory status (rate, degree of dyspnea, ABGs).Deep Vein Thrombosis/Acute Arterial Occlusion:
- Observe extremities and palpate pulses of affected extremities every hour. Notify health care professional immediately if circulatory impairment occurs. Computerized tomography, impedance plethysmography, quantitative Doppler effect determination, and/or angiography or venography may be used to determine restoration of blood flow and duration of therapy; however, repeated venograms are not recommended.Cannula/Catheter Occlusion:
- Monitor ability to aspirate blood as indicator of patency. Ensure that patient exhales and holds breath when connecting and disconnecting IV syringe to prevent air embolism.
Lab Test Considerations:
Hematocrit, hemoglobin, platelet count, fibrin/fibrin degradation product (FDP/fdp) titer, fibrinogen concentration, prothrombin time, thrombin time, and activated partial thromboplastin time may be evaluated before and frequently during therapy. Bleeding time may be assessed before therapy if patient has received platelet aggregation inhibitors.
- Obtain type and crossmatch and have blood available at all times in case of hemorrhage.
- Stools should be tested for occult blood loss and urine for hematuria periodically during therapy.
High Alert: If local bleeding occurs, apply pressure to site. If severe or internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote.