What intervention does the nurse include in the plan of care for a patient receiving a continuous intravenous infusion of heparin?
A) Avoiding intramuscular injections
B) Assessing for symptoms of respiratory depression
C) Measuring hourly urinary outputs
D) Monitoring BP hourly
A
Feedback:
The most commonly encountered adverse effect of the anticoagulants is bleeding, ranging from bleeding gums during toothbrushing to severe internal hemorrhage. Avoid all invasive procedures, including giving IM injections, while the patient is on heparin therapy. It would not be necessary to assess for respiratory depression, measure hourly output, or monitor the BP hourly as related because of heparin administration.
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