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1. Question
The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:
Correct
Answer D is correct.
Rationale:After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
Incorrect
Answer D is correct.
Rationale:After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
Heparin, prepared commercially from animal tissue, is an antithrombolytic agent used to prevent clot formation. Because it doesn’t affect the synthesis of clotting factors, heparin can’t dissolve already formed clots.
Administration. Very large MW and very acidic- therefore not available orally. SC (give in the abd, DO NOT aspirate or massage) IV (intermittent or continuously infusion) Results seen within minutes of IV administration. Dosage adjustments per Heparin Nomogram or physician order. (see attachment to PP handout) Very rapid acting – short half-life (1-2H) Most over-doses can be reversed by simply D/C drug. Lab monitoring of aPTT (partial thromboplastin time) required. Antidote (neutralizes the heparin) protamine sulfate.
Adverse reactions
One advantage of heparin and its derivatives is that they produce relatively few adverse reactions. These reactions can usually be prevented if the patient’s PTT is maintained within the therapeutic range (11/2 to 2 times the control).
