Assessment

• Monitor blood pressure, pulse, and respiratory status as indicated by severity of bleeding

• Monitor for overt bleeding every 15–30 min

• Monitor neurologic status (pupils, level of consciousness, motor activity) in patients with subarachnoid hemorrhage

• Monitor intake and output ratios frequently; notify physician if significant discrepancies occur

• Assess for thromboembolic complications (especially in patients with history). Notify physician of positive Homans' sign, leg pain and edema, hemoptysis, dyspnea, or chest pain

• Monitor platelet count and clotting factors prior to and periodically throughout therapy in patients with systemic fibrinolysis

» CPK, AST, and serum aldolase may indicate myopathy

» May serum potassium

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