# A client on day 7 of unfractionated heparin for DVT shows a platelet drop from 245 to 95 thousand and a new right-leg DVT extension. Which actions should the nurse anticipate? Select all that apply.

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> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

A client on day 7 of unfractionated heparin for DVT shows a platelet drop from 245 to 95 thousand and a new right-leg DVT extension. Which actions should the nurse anticipate? Select all that apply.

1

Discontinue all heparin including line flushes and LMWH

2

Transfuse platelets to maintain count above 100 thousand

3

Resume warfarin alone once platelets exceed 150 thousand

4

Send HIT antibody (PF4) ELISA and serotonin release assay

5

Initiate argatroban or bivalirudin as a non-heparin anticoagulant

## Explanation

HIT is a prothrombotic immune reaction to heparin-PF4 complexes. ALL heparin must be stopped including flushes and LMWH. A non-heparin anticoagulant (argatroban or bivalirudin) is initiated for active or risk-of thrombosis. Confirmatory testing is PF4 ELISA followed by SRA. Platelet transfusion is generally AVOIDED — it fuels thrombosis. Warfarin must NOT be started alone in acute HIT due to protein-C depletion causing skin necrosis and venous limb gangrene; it is added only after platelets recover and overlapped with a non-heparin agent.

## In-depth explanation

4Ts score guides probability: 6-8 high, 4-5 intermediate, 0-3 low. Stop heparin BEFORE the result returns when probability is intermediate or high.

## Clinical scenario

4T score: timing 2, thrombocytopenia 2, thrombosis 2, other causes unlikely 1 = 7 (high probability HIT).

## Key concepts

- **HIT type II** — Immune-mediated heparin-induced thrombocytopenia with thrombosis risk.
- **argatroban** — Direct thrombin inhibitor; non-heparin anticoagulant for HIT.
- **4Ts score** — Pretest probability scoring for HIT: Thrombocytopenia, Timing, Thrombosis, oTher causes.

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