Heparin Nursing Implications and Patient Teachings

Last updated on December 28th, 2023

Introduction

In this article, you’ll learn about heparin nursing implications and patient teachings. Also, its dosage, indication, side effects.

Generic Name: Heparin Sodium

Brand Names: Hepalean (CAN), Heparin Leo (CAN), Hep-Lock, Hep-Lock U/P, Heparin Sodium Injection

Heparin Class and Category

Pharmacologic class: Anticoagulant.

Therapeutic class: anticoagulant, antithrombotic

Pregnancy category: C

Heparin Dosage

Adults: subcutaneous: 5000-10,000 units q4-12h; IV bolus: 5000 units; infusion: 20,000-40,000 units over 24 hr based on aPTT
Children: IV bolus: 50 units/kg; followed by 5-100 units/kg q4h based on APTT

Heparin Pharmacokinetics and Pharmacodynamics

Route	Onset	Peak	Duration
IV	immediate	5 – 10 min	2 – 6 hr
SubQ	20 – 60 min	2 hr	8 – 12 hr

Absorption: Heparin is effectively absorbed when administered subcutaneously.

Distribution: Protein binding is very high.

Metabolism: Hepatic.

Half-life: 1 – 6 hr

Excretion: Mostly the kidneys eliminate inactive substances through urine.

Heparin Mechanism of Action

By increasing the inhibitory actions of antithrombin III, it prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin. Thrombin is required for the conversion of fibrinogen to fibrin; clots cannot form without fibrin.

Heparin inhibits factor Xa and hinders the conversion of prothrombin to thrombin at low dosages. Heparin inactivates thrombin at large dosages, inhibiting fibrin production and clot extension.

What are the indications of heparin?

Heparin indications include:

Deep venous thrombosis (DVT).
Pulmonary embolism (PE).
Myocardial infarction (MI).
Disseminated intravascular coagulation (DIC).
Disseminated intravascular clotting syndrome.
Open heart surgery.
To maintain patency of indwelling IV devices.
To treat atrial fibrillation-related thromboembolic complications.
Anticoagulant for extracorporeal and dialysis procedures.

What are the contraindications of heparin?

The contraindications of heparin are:

Hypersensitivity to heparin.
Active bleeding that is uncontrolled (unless caused by disseminated intravascular coagulation [DIC]).
Severe thrombocytopenia.
Heparin-induced thrombocytopenia (HIT).
Heparin-induced thrombocytopenia with thrombosis (HITT).
Positive HIT antibody.

Caution: Allergic to pork; GI ulcers; hemophilia; concomitant platelet inhibitors; severe hypertension; menses; recent lumbar puncture or spinal anesthesia; recent major surgery; trauma.

Heparin Interactions

Heparin effect is increased with aspirin, NSAIDs, thrombolytics, probenecid
Heparin effect is decreased with nitroglycerin, protamine sulfate
Increases free fatty acids, serum ALT, AST, K+, INR, PT, PTT
Decreases serum cholesterol, platelets.

Herbal/food interactions

Herbs containing anticoagulant/antiplatelet properties may increase the risk of bleeding. These herbs include:

Garlic
Ginger
Ginkgo biloba
Arnica
Anise
Chamomile
Clove
Dong quai
Feverfew
Green tea
Horse chestnut

What are heparin side effects?

Heparin side effects / adverse reactions include:

Itching
Burning
Dizziness
Chills
Injection site reaction such as hematoma
Bleeding
Nausea and vomiting
Ecchymoses
Hematuria
Angioedema
Osteoporosis
Stroke
Heparin-induced thrombocytopenia
Life-threatening adverse effects: Hemorrhage

Heparin Nursing Implications [Nursing Considerations]

Heparin nursing considerations are divided into nursing assessment, interventions, and evaluation.

Heparin nursing assessment

Obtain detailed medical and drug related history including hypersensitivity, possible drug-drug and drug-food interactions.
Assess the patient for signs of bleeding (such as gums, petechiae, ecchymosis, black tarry stools, melena, coffee-ground vomitus, hematuria, epistaxis).
Determine baseline CBC and coagulation profile before initiating the heparin treatment.

Heparin nursing diagnosis

Ineffective peripheral/cerebral tissue perfusion
Risk for ineffective peripheral/cerebral tissue perfusion
Risk for bleeding related to adverse effect of heparin therapy
Deficient knowledge related to lack of past experience with anticoagulant therapy and disease process.

Heparin nursing interventions/ actions

Assess vital signs. A sudden rise in pulse rate proceeded by a fall in systolic pressure may suggest a fluid volume deficit caused by external or internal bleeding.
Monitor aPTT before administering heparin and 6 hours after starting or any modification in dosage (or according to clinical guideline) until the maintenance dose is established, then check aPTT every 24 hours (or according to clinical guideline).
Monitor CBC daily. Because anticoagulants can decrease hematocrit levels and HIT may occur; and low hemoglobin may indicate internal bleeding.
Regularly assess for bleeding in the patient’s mouth (gum bleeding), nose (epistaxis), urine (hematuria), and skin (ecchymosis).
Evaluate stool for occult blood.
Monitor for worsening thrombosis on a daily basis in affected areas.
Observe any increasing menstrual bleeding.

IV administration considerations

Administer undiluted loading dose over 1 minute.
Obtain coagulation profile before initiating the continuous IV infusion.
Prepare the infusion by diluting 25,000 units/250-500 mL of 0.9 NaCl or D5W. Mix well the solution to prevent medication pooling.
Ensure flow rate is accurate, preferably use infusion pump to administer continuous IV heparin.
Monitor aPTT after 6 – 8 hours of continuous I.V. therapy. Use the opposite arm to the infusion site to collect the sample.
Apply pressure dressing after collecting blood samples.

Subcutaneous (SQ) administration considerations

Use a new 25G needle to administer heparin subcutaneously. Remember to change the needle after loading the injection.
Administer subcutaneous heparin in the abdomen between the pelvic bones, and at least 5 cm (2 inches) away from the umbilicus.
When administering subcutaneous heparin injection, do not aspirate and do not massage before or after the injection. Just apply gentle pressure for about a minute after giving injection.
Rotate the injections sites.
Assess the injection sites for signs of bleeding, hematoma, and necrosis.
Do not give heparin intramuscularly (IM) and also avoid all intramuscular (IM) injections that may cause bleeding or hematoma.

Evaluation

Evaluate the effectiveness of the drug: attainment of desired therapeutic response, such as DVT and pulmonary emboli prevention; aPTT, PT and INR levels are within the normal range; patient remain adverse effects free.

Pregnancy/breastfeeding considerations for heparin

Use with caution, especially throughout the last trimester and the immediate postpartum period because it may increase risk of hemorrhage.
Risks to fetal is unknown.
Heparin does not cross placenta and not excreted in breastmilk.
Consult the physician before starting lactation.

What is the patient teaching for heparin?

The patient teaching for heparin by the nurse should include the following points.

Teach the patient how to take heparin.
Advise the patient to avoid OTC medicines without consulting the prescriber. Because it may interact with heparin and create harmful effects.
Teach the patient to recognize signs of bleeding (eg; reddish or dark urine, reddish or black feces, coffee-ground vomitus, blood-tinged cough mucus, gum bleeding, stroke symptoms, nosebleeds, or increased or prolonged menstruation) and to report any signs as soon as possible.
Teach the patient to inform dentist and other doctors regarding heparin treatment.
Teach the patient to reduce the risk of bleeding and encourage him/her to use a soft-bristled toothbrush, an electronic razor, and to avoid injuries.
Educate the patients who are taking heparin subcutaneously that skin necrosis has been observed after heparin subcutaneous administration, and to notify the doctor if any anomalies arise at injection sites.
Inform the patient that temporary hair loss is possible with heparin therapy.
Advise patient to reduce alcohol consumption.
Instruct the patient to carry identification card indicating heparin therapy.

Treatment of Overdose

Withdraw the heparin products
Administer protamine sulphate as advised (usually 1 mg protamine/100 units heparin)
Administer fresh-frozen plasma (FFP) as advised

Conclusion

You learned about heparin nursing implications (aka nursing considerations) and patient teaching in this article. In addition, you’ve learned about heparin’s mechanism of action, pharmacokinetics, dosage, indications, contraindications, and side effects.