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Patients Receiving Heparin Assessment Prior to administration, Study notes of Nursing

Evaluate effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”). Page 3. Nursing Process Focus:.

Typology: Study notes

2021/2022

Uploaded on 09/27/2022

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Nursing Process Focus:
Patients Receiving Heparin
Assessment
Prior to administration:
Obtain complete heath history including
allergies, drug history and possible drug
interactions.
Assess baseline coagulation studies and
CBC
Assess for history of bleeding disorders,
GI bleeding, cerebral bleed, recent trauma
Obtain patient’s drug history including
use of over the counter medications that
might effect coagulation and assess
allergies
Assess for history of alcohol abuse
Potential Nursing Diagnoses
Injury, Risk for, (bleeding) related to side
effects of anticoagulant medication
Tissue perfusion, Risk for Ineffective,
related to hemorrhage or venous
thrombosis related to side effects of
anticoagulant therapy
Planning: Patient Goals and Expected Outcomes
The patient will:
Remain free of unusual bleeding
Maintain effective tissue perfusion
Implementation
Interventions and (Rationales) Patient Education/Discharge Planning
Monitor for bleeding. Check color of
urine, occult blood in stool, and/or
changes in vital signs. (Patients with
history of peptic ulcer disease,
alcoholism, kidney or liver disease, and
the elderly are at greatest risk for
bleeding)
Advise patient to:
Use a soft toothbrush and an electric
shaver.
Avoid all contact sports while on heparin
therapy.
Report even minor injuries to the health
care provider
Wear identification stating patient is on
anticoagulant therapy if they are receiving
SQ heparin outside the hospital setting
Monitor PTT for therapeutic values (1
½ -2 ½) baseline.
Explain to patient and caregivers rationale
for frequent lab tests with IV heparin.
Encourage smoking cessation.
(Nicotine decreases the effect of
heparin. Patient should not smoke
while on heparin therapy.)
Advise patient to avoid nicotine while on
heparin therapy.
Monitor CBC in female patients who
are menstruating. (Anticoagulation
may cause excessive blood loss during
menses.)
Advise patient that heparin may increase
menstrual bleeding and to report any
increased bleeding to the health care
provider
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Nursing Process Focus: Patients Receiving Heparin

Assessment Prior to administration:

  • Obtain complete heath history including allergies, drug history and possible drug interactions.
  • Assess baseline coagulation studies and CBC
  • Assess for history of bleeding disorders, GI bleeding, cerebral bleed, recent trauma
  • Obtain patient’s drug history including use of over the counter medications that might effect coagulation and assess allergies
  • Assess for history of alcohol abuse

Potential Nursing Diagnoses

  • Injury, Risk for, (bleeding) related to side effects of anticoagulant medication
  • Tissue perfusion, Risk for Ineffective, related to hemorrhage or venous thrombosis related to side effects of anticoagulant therapy

Planning: Patient Goals and Expected Outcomes

The patient will:

  • Remain free of unusual bleeding
  • Maintain effective tissue perfusion Implementation Interventions and (Rationales) Patient Education/Discharge Planning
  • Monitor for bleeding. Check color of urine, occult blood in stool, and/or changes in vital signs. (Patients with history of peptic ulcer disease, alcoholism, kidney or liver disease, and the elderly are at greatest risk for bleeding)

Advise patient to:

  • Use a soft toothbrush and an electric shaver.
  • Avoid all contact sports while on heparin therapy.
  • Report even minor injuries to the health care provider
  • Wear identification stating patient is on anticoagulant therapy if they are receiving SQ heparin outside the hospital setting
  • Monitor PTT for therapeutic values ( ½ -2 ½) baseline.
  • Explain to patient and caregivers rationale for frequent lab tests with IV heparin.
  • Encourage smoking cessation. (Nicotine decreases the effect of heparin. Patient should not smoke while on heparin therapy.)
  • Advise patient to avoid nicotine while on heparin therapy.
  • Monitor CBC in female patients who are menstruating. (Anticoagulation may cause excessive blood loss during menses.)
  • Advise patient that heparin may increase menstrual bleeding and to report any increased bleeding to the health care provider

Evaluation of Outcome Criteria

Evaluate effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”).

  • To wear ID stating patient is on anticoagulant therapy
  • To keep all appointments for lab work
  • Provide instruction related to dietary considerations during Warfarin therapy.
  • (Vitamin K is the antidote for warfarin and is found in high quantity in green leafy vegetables.)
  • Advise patient to eat consistent amounts of foods high in Vitamin K such as green leafy vegetables.

Evaluation of Outcome Criteria

Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Abciximab (ReoPro)

Assessment Prior to administration:

  • Obtain complete health history, including allergies, drug history and possible drug interactions.
  • Assess vital signs, APTT, PT, CBC, bleeding time

Potential Nursing Diagnoses

  • Tissue perfusion, Risk for Ineffective, related to ineffectiveness of abciximab
  • Injury, Risk for, (bleeding) related to adverse effects of abciximab

Planning: Patient Goals and Expected Outcomes

The patient will:

  • Demonstrate adequate tissue perfusion throughout drug therapy
  • Avoid occurrence of unusual or excessive bleeding Implementation Interventions and (Rationales) Patient Education/Discharge Planning
  • Monitor vital signs frequently during infusion. (Abciximab doubles risk of major bleeding especially if PCTA site is in the femoral artery) - Advise patient that careful monitoring will be done while the medication is infusing to assess for hemorrhage.
  • Monitor all potential bleeding sites such as old IV sites. - Instruct patient to report any bleeding from I.V. or other puncture sites.
  • Assist with cardiac monitoring. (Patient must be on cardiac monitor during infusion, dysrhythmias may occur with reperfusion.) - Advise patient of rationale for cardiac monitoring.
  • Monitor for evidence of excessive bleeding, symptoms of stroke. (Medication is give in conjunction with aspirin and heparin to facilitate revascularization in acute coronary syndrome.)

Advise patient to:

  • Notify the health care provider at the first sign of bleeding
  • Immediately report severe headache, visually changes or changes in sensorium
  • Monitor Hgb, Hct, platelets, PT / INR, APTT every 2-4 hours during first 24 hours. Discontinue medication and heparin if severe bleeding occurs.
  • Advise patient of rationale for frequent lab assessments.

Evaluation of Outcome Criteria

Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Alteplase

Assessment Prior to administration:

  • Obtain complete health history, including allergies, drug history, and possible drug interactions.
  • Assess lab values; APTT, PT, Hgb, Hct, platelet count
  • Asses vital signs
  • Assess for menses in women, recent surgery or trauma, bleeding disorders, or history of hemorrhagic stroke or GI bleeding

Potential Nursing Diagnoses

  • Injury, Risk for (bleeding) related to adverse effects of thrombolytic therapy
  • Cardiac Output, Risk for Decreased, related to reperfusion of myocardium
  • Tissue perfusion, Risk for Ineffective, related to increase in size of thrombus or ineffective effect of thrombolytic therapy
  • Knowledge deficient related to thrombolytic therapy

Planning: Patient Goals and Expected Outcomes

The patient will:

  • Avoid occurrence of excessive bleeding
  • Demonstrate knowledge of drug action and side effects
  • Maintain effective tissue perfusion
  • Maintain vital signs within normal limits Implementation Interventions and (Rationales) Patient Education/Discharge Planning
  • Monitor vital signs every 15 minutes during first hour of infusion, then every 30 minutes during remainder of infusion. (Patient is at risk for excessive bleeding during revascularization.)
  • Patient should be moved as little as possible during the infusion to prevent internal injury

Advise patient:

  • Regarding need for frequent vital signs.
  • That activity will be limited during infusion and pressure dressing may be needed to prevent any active bleeding
  • Monitor neurological status frequently (massive cerebral hemorrhage could occur).

Instruct patient:

  • About assessments and why they are necessary
  • To report change in sensorium, headache, visual changes
  • Assist with monitoring cardiac rate and rhythm while medication is infusing. (Dysrhythmias may occur with reperfusion of myocardium.)
  • Advise patient that cardiac rhythm will be monitored during therapy.
  • Start IV lines and insert foley catheter prior to beginning therapy (to decrease chance of bleeding from those sites).
  • Inform patient about procedures and why they are necessary.
  • Monitor CBC during and after therapy (for indications of blood loss due to internal bleeding). Patient has increased risk of bleeding for 2-4 days post infusion. - Instruct patient of increased risk for bleeding, activity restriction, and frequent monitoring during this time.

Evaluation of Outcome Criteria Evaluate effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).