A client who is receiving IV heparin has a PTT reported by the lab as 101 . Appropriate actions by the nurse include (Select all that apply)

Question

a. continuing to monitor the heparin infusion.
b. instituting safety precautions.
c. notifying the physician.
d. ordering another PTT in the morning.
e. turning off the heparin IV.

Answer 1

B, C, E
Bleeding can occur in the client receiving anticoagulant therapy. Heparin infusions are monitored with the PTT. Therapeutic levels are generally greater than 60, but at 1.5-2.5 times the baseline (normal is around 25-35). A PTT of 101 is a critical result and the nurse should (1) stop the heparin infusion, (2) notify the physician, and (3) place the client on bleeding precautions. A small injury to the client can cause bleeding. The client can also have spontaneous bleeding. The nurse should observe the client for bleeding, as evidenced by frank hemorrhage, changes in mental status, pink-tinged or frank blood in the urine, dark or tarry stools, and bleeding after brushing the teeth.