What is the nurses priority assessment for a patient receiving heparin treatment?

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This review will break down what you need to know for your pharmacology exams about the medication Heparin. 

Heparin is an anticoagulant that is used to treat and/or prevent blood clots. It is vital the nurse knows how the drug works, side effects, how to monitor the aPTT, and education to provide to the patient etc.

Don’t forget to take the Heparin NCLEX Question quiz.

Heparin Nursing Review Lecture

Heparin (Unfractionated Heparin) Pharmacology NCLEX Review

Always ask yourself these 5 questions when you see a drug name to help you understand how the drug works, your role as a nurse, and what information will be asked on an exam about the drug:

Name (specifically the family name)? This will tell how the drug works.

Used for? This will tell you WHY the drug was ordered…what condition is this medication treating in your patient?

Responsibilities as the nurse? This will tell you what your role is as the nurse and what you need to monitor in the patient.

Side effects? Know the common side effects of the medications

Education pieces for the patient? As the nurse we play a HUGE role in educating our patients on how to take the drug, what to watch out for, and when to call the doctor.

Now, using those 5 questions let’s go over what you need to know about Heparin for exam:

Name?

We’re talking about Heparin

• It’s part of the indirect thrombin inhibitors family, and it’s an anticoagulant.
  • Heparin indirectly inhibits thrombin…..HOW?
    • By affecting the intrinsic pathway of clotting
      • This pathway is normally activated by internal vascular trauma.
    • It does this by enhancing the activity of antithrombin III ( a natural substance in our body). This substance inactivates enzymes that play a role in the clotting process.
    • When it is activated (antithrombin III) it will prevent the activation of thrombin (which converts fibrinogen to fibrin).
    • Therefore, what’s happening is that this medication, Heparin, is binding with this natural substance (antithrombin III) in our body and amplifying how it works.
    • Result? Slows down the clotting process and helps prevent blood clots.
    • When coagulation occurs abnormally, a venous thromboembolism (VTE) can occur. There are two types of these:
      • Deep vein thrombosis (DVT): this is where a clot forms within a vessel. It can break off and travel in circulation and when it does this it is known as an…..
      • Embolism: The most common type of embolism that can happen is a pulmonary embolism. This is where the DVT broke off and travelled into circulation where it went to the lungs. An embolism can also cause a stroke or heart attack.
    • It’s important to note anticoagulants do NOT dissolve or break up the clot. They just prolong how long it takes the blood to clot.

Used for?

Preventing or treating blood clots

What kind of conditions can benefit from Heparin?

• Preventing or treating VTEs or PE (pulmonary embolism)
• Stroke (certain types)
• Atrial fibrillation (erratic heart impulses lead the heart not to empty fully and blood can pool, which forms a clot)
• clot prevention with certain surgeries…example: cardiac or hip

Responsibilities of Nurse?

(hint: remember this information)

Administered subcutaneous or intravenous via a continuous infusion:

• Given continuous IV: patient will be on a Heparin drip protocol with specific guidelines to follow based on the patient’s aPTT level. The aPTT will be drawn every 4-6 hours depending on the protocol.
  • The Heparin drip will be titrated base on the aPTT.
    • Example:
      • If the aPTT is too low, the patient may need a bolus of Heparin and the drip rate increased.
      • If the aPTT is too high, the patient may need the drip turned off for 1 hour and the drip rate decreased.
      • If the aPTT is within the therapeutic range (see range below), there is no change to the drip until the next lab draw for the aPTT.

Heparin is weight-based: the nurse will need to obtain a current and accurate weight on the patient’s so proper dosing can be administered.

aPTT: activated partial thromboplastin time

What’s PTT vs aPTT?

They both measure the same thing, BUT aPTT has an activator added to it to speed up the clotting time for the test. Therefore,  it has a more narrow range than a PTT.

This blood test measures the intrinsic and common pathways of the coagulation process. So, it will assess how long it takes for certain coagulation factors to work to make a clot.

It’s measured in seconds and a normal range for the aPTT is 30-40 seconds (ranges slightly vary based on the lab).

****Remember in order for Heparin to work (hence prevent clots) the patient has to be THERAPEUTIC with their aPTT.

****Heparin therapeutic range for the aPTT: 1.5-2.5 times the normal value range……example: 60-80 seconds (approximate range….varies on protocol and labs).

What to remember?

aPTT less than 60? Patient is not therapeutic (may need bolus and rate increased)

aPTT greater than 80? Patient is at risk for bleeding (drip may be stopped for an hour (Heparin has a short half-life) and then it may be restarted at a lower rate)

• If administered subcutaneous, know how to give it and where……
  • Site: fatty tissue of the abdomen….stay at least 2 inches away from the belly button and 1 inch away from scars (won’t absorb the medication)
  • Always rotate sites (see where the last nurse administered the injection in the chart and ask the patient)
  • Don’t rub or massage the area!

Monitor for bleeding (in unusual places):

• Oozing at the gums
• Dark, tarry stool “melena”
  • Positive stool guaiac
• Reddish, pink urine “Hematuria”
• Vomiting blood or coffee ground appearance “hematemesis”
• Bruising for no cause
• Nosebleeds
• Tachycardia and hypotension
• Severe headache (bleeding in brain)
• Monitor CBC (hbg and hct)

Monitor for Heparin-induced Thrombocytopenia (HIT):

• What is this? The body makes antibodies against the Heparin because it’s binding to platelet factor 4 (a blood protein). The created antibodies will bind to the Heparin and PF4 complex, which activates the platelets. Small clots will form (hence new clots or worsening of current clots) and the platelet count falls…hence thrombocytopenia.
• Monitor: CBC (platelets, hgb, and hct), assess for signs and symptoms of new clot formation (signs and symptoms vary depending on clot location): red, swollen, hard areas, chest pain, shortness of breath etc.
• What happens if this develops?
  • Heparin discontinued and started on direct thrombin inhibitors (argatroban, bivalirudin etc.)

Be familiar with the antidote for Heparin, which is protamine sulfate.

Avoid IM injections…pick another route and hold firm, direct pressure after drawing blood (remember the patient bleeds easily)

Some patients will be started on Warfarin for long-term anticoagulation. Warfarin takes 3-5 days for the patient to become therapeutic. So, the patient may be on Heparin too until the INR level is therapeutic, and then once the INR is therapeutic the Heparin is discontinued.

Heparin can used in pregnancy…..Warfarin cannot!

Side effects?

Other side effects beside excessive bleeding, HIT:

• Osteoporosis: Heparin can stimulate osteoclasts and inhibit osteoblast activity, which affects the strength of the bones. This tends to happen with long-term/high doses of Heparin usage.
• Other signs and symptoms: hair loss, rashes

Education pieces for the patient?

(hint: remember this information)

• Teach the patient to monitor for signs and symptoms of excessive bleeding.
• Use soft bristle toothbrush and electric razors.
• Avoid contact sports.
• Tell all care providers that you’re on Heparin, especially prior to any procedures.
• Do not take ASA or NSAIDs (increases risk of bleeding) or OTC health supplements without speaking to doctor.
• How to administer subq heparin, if taking this route.
• If patient has an accident that causes bleeding or has blood drawn etc., they will need to hold firm direct pressure.

References:

Food and Drug administration. (2017). Heparin Sodium, for intravenous use Ebook]. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/017029s140lbl.pdf

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