# Situation: A 45-year-old woman comes to the emergency room (ER) with sudden shortness of breath and right-sided pleuritic chest pain that began 2 hours ago, the day after a 14-hour bus trip. She takes a combined estrogen–progestin oral contraceptive. Her right calf is swollen and tender. She weighs 70 kg and has no known drug allergies. Despite heparin and a 500 mL fluid bolus, her blood pressure stays at 78/48 mmHg, and the team plans systemic thrombolysis with alteplase. While reviewing her history, which finding should the nurse report to the provider as an absolute contraindication?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629792  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 45-year-old woman comes to the emergency room (ER) with sudden shortness of breath and right-sided pleuritic chest pain that began 2 hours ago, the day after a 14-hour bus trip. She takes a combined estrogen–progestin oral contraceptive. Her right calf is swollen and tender. She weighs 70 kg and has no known drug allergies.

Despite heparin and a 500 mL fluid bolus, her blood pressure stays at 78/48 mmHg, and the team plans systemic thrombolysis with alteplase. While reviewing her history, which finding should the nurse report to the provider as an absolute contraindication?

## 보기

1. Intracranial hemorrhage 6 years ago with full recovery **✔ 정답**
2. Menstrual period that began yesterday with a normal flow
3. Heparin infusion that has been running for the past 2 hours
4. Ischemic stroke 8 months ago with full recovery of function

**정답: 1**

## 해설

Systemic thrombolysis is used for pulmonary embolism with persistent hypotension. Absolute contraindications include any prior intracranial hemorrhage, ischemic stroke within the past 3 to 6 months (depending on the guideline), recent head trauma or brain or spinal surgery, intracranial tumor, and active internal bleeding. A hemorrhage inside the skull 6 years ago still counts, whereas an ischemic stroke 8 months ago lies outside that window.

## 심화 해설

Clinical context This patient has a high-risk (massive) pulmonary embolism. The combination of sudden dyspnea, pleuritic chest pain after prolonged immobilization, a swollen tender calf suggesting deep vein thrombosis, and persistent hypotension despite heparin and fluids defines hemodynamic instability. In this situation, systemic thrombolysis is indicated to rapidly dissolve the clot and reduce right ventricular afterload.

Why option 1 is the answer A history of any prior intracranial hemorrhage is an absolute contraindication to systemic thrombolysis, regardless of how long ago it occurred or how complete the recovery was. The risk of catastrophic rebleeding into the brain is unacceptably high because alteplase is a systemic fibrinolytic that dissolves protective hemostatic plugs throughout the body, not just the pulmonary clot. The 6 years since the bleed does not reduce this risk to an acceptable level.

Why the other options are not absolute contraindications

| Option | Classification | Reasoning |
| --- | --- | --- |
| 2. Menstrual period that began yesterday | Not a contraindication | Normal menstrual flow is not active internal bleeding in a critical location. It may increase blood loss slightly but does not pose a life-threatening risk. |
| 3. Heparin infusion running for 2 hours | Expected, not a contraindication | Heparin is standard initial therapy for PE. Thrombolysis is added on top of heparin in massive PE; the infusion does not preclude alteplase. |
| 4. Ischemic stroke 8 months ago | Relative or outside window | Ischemic stroke within the past 3 to 6 months is an absolute contraindication. At 8 months, the risk has decreased enough that thrombolysis may be considered if the benefit outweighs the risk. |

Pathophysiology of the contraindication Alteplase converts plasminogen to plasmin, which degrades fibrin clots and also fibrinogen. In a patient with a prior intracranial hemorrhage, the cerebral vasculature may have residual structural weakness, microaneurysms, or areas of impaired autoregulation. When systemic fibrinolysis is introduced, any subclinical or healed bleeding site in the brain can rupture again, leading to a potentially fatal hemorrhagic stroke. This is why the contraindication is permanent, not time-limited.

Nursing priority Before alteplase is administered, the nurse must complete a thorough screening for contraindications and Key point! report any history of intracranial bleeding, recent ischemic stroke, major surgery, or active bleeding immediately to the provider. The decision to proceed with thrombolysis in a patient with a relative contraindication requires a careful risk-benefit discussion, but an absolute contraindication such as prior intracranial hemorrhage removes thrombolysis as an option entirely.

Distinguishing the two neurologic histories The critical distinction is between hemorrhagic and ischemic events. An ischemic stroke leaves a time-limited window of risk because the infarcted brain tissue is most vulnerable to hemorrhagic transformation in the first weeks to months. A prior hemorrhage, however, indicates a structural or hemostatic predisposition that does not resolve with time. Watch out! Do not confuse the two: ischemic stroke has a time window (3–6 months), while intracranial hemorrhage has no time window and remains an absolute contraindication permanently.

## 임상 시나리오

Thrombolysis Safety Check for Massive PEAbsolute contraindications must be reported before alteplase administration
For a patient with massive pulmonary embolism and persistent hypotension despite heparin and fluids, systemic thrombolysis is indicated. Before giving alteplase, the nurse must screen for absolute contraindications. Any history of intracranial hemorrhage, regardless of time elapsed or functional recovery, is an absolute contraindication. This includes a bleed 6 years ago.

An ischemic stroke within the past 3 to 6 months is also an absolute contraindication. A stroke 8 months ago is outside this window and is not an absolute contraindication. Normal menstrual flow is not active internal bleeding in a critical location and does not preclude thrombolysis. A running heparin infusion is expected initial therapy and does not contraindicate alteplase.

CautionReport any prior intracranial hemorrhage immediately to the provider before alteplase is given. The risk of catastrophic rebleeding is unacceptably high because alteplase dissolves protective hemostatic plugs throughout the body, not just the pulmonary clot.

## 핵심 개념

- **Massive Pulmonary Embolism** — PE causing sustained hypotension (systolic BP
- **Systemic Thrombolysis** — Intravenous administration of a fibrinolytic agent such as alteplase to dissolve pathological clots throughout the body, used for hemodynamically unstable PE.
- **Absolute Contraindication** — A clinical condition in which a therapy must not be given because the risk of serious harm clearly outweighs any potential benefit.
- **Intracranial Hemorrhage** — Bleeding within the skull, including intracerebral, subarachnoid, or subdural locations; any prior history is an absolute contraindication to thrombolysis.
- **Alteplase** — A recombinant tissue plasminogen activator (tPA) that converts plasminogen to plasmin, leading to systemic fibrinolysis and clot breakdown.

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