The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT)

Question

At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply.
a. Notify the prescriber before giving the medication.
b. Give subcutaneous heparin as ordered.
c. Hold the medication dose at this time.
d. Chart the reason the medication was not given.
e. Assess for other significant signs and symptoms.
f. Record abnormal findings in the patient's health record.

Answer 1

C, D, E, F
Heparin, an anticoagulant, should be given to achieve one and a half to two times the normal clotting times and PTT. Because the findings of the laboratory values are four times the normal range and petechiae are present, this indicates a significant risk for bleeding. Therefore, the heparin should be held; the physician should be notified immediately. The nurse must document why the medication was not given and should assess for other significant findings. Omitted or delayed administration must be charted as soon as possible with an explanation for the delay or omission. The nurse will notify the provider but not give the medication. Heparin is given via a subcutaneous injection; however, because it is being held, it will not be administered or documented as "given." Because the findings regarding the heparin and its use are abnormal, the nurse would not document normal findings.