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
