Heparin Nursing Implications
Heparin Nursing Resposibilities
Heparin is a type of medication classified as an anticoagulant. An anticoagulant is a drug class that acts on the body by preventing the formation of clots, which are either induced by medical conditions or medical procedures. Because of this, heparin has very crucial and potent effects that would need expertise when given to patients.
***For the NCLEX exam, it is important to know that Protamine is the antidote or reversal agent for Heparin.***
Indications of Heparin
Heparin is administered to manage the following conditions:
- Prophylaxis and treatment for venous thromboembolism, pulmonary embolism, and peripheral arterial embolism
- Atrial fibrillation with embolization
- Treatment of acute and chronic disseminated intravascular coagulation (DIC)
- Prevention of clotting in procedures, usually during arterial and cardiac surgery
- As an anticoagulant used in blood transfusions, dialysis, extracorporeal circulation
Dosages of Heparin
The adult and pediatric dosages of heparin are as follows (the following dosages are what may be ordered by the medical provider. Be sure to check the provider orders):
- Heparin for Deep vein thrombosis (DVT) and Pulmonary embolism (PE)
- As prophylaxis for adults: 5000 units subcutaneously every 8 to 12 hours or 7500 units subcutaneously every 12 hours
- As prophylaxis for pediatrics: 100-150 units/kg IV once (off label use)
- As treatment for adults: 5000 units intravenous (IV) bolus then continuous infusion of 1300 units/hr; or 80 units/kg IV bolus then continuous infusion of 18 units/kg/hr; or 250 units/kg (alternate with 17,500 units) subcutaneously then 250 units/kg every 12 hours.
- As treatment for pediatrics (<1 year): loading dose of 75 units/kg IV then 28 units/kg/hr IV as an initial maintenance dose (off label use)
- As treatment for pediatrics (>1 year): loading dose of 75 units/kg IV then 20 units/kg/hr IV as an initial maintenance dose (off label use)
- As treatment for pediatrics through intermittent IV injection: 50-100 units/kg initial IV infusion then 100 units/kg IV drip every 4 hours as a maintenance dose
2. Heparin for Acute coronary syndromes (ACS)
- Percutaneous coronary intervention (PCI): Initial IV bolus of 70-100 units/kg (if without GPIIb/IIIa inhibitor) or initial IV bolus of 50-70 units/kg (if with GPIIb/IIIa inhibitor)
- ST elevated myocardial infarction (STEMI): IV bolus of 60 units /kg (max of 4000 untis) then 12 units/kg/hr (max of 1000 units/hr) as continuous IV infusion with doses adjusted to maintain aPTT of 50-70 seconds.
- Unstable angina/ non-ST elevated myocardial infarction (NSTEMI): initial IV bolus of 60-70 units/kg (max of 5000 units) then IV infusion of 12-15 units/kg/hr (max of 1000 units/hr) with doses adjusted to maintain aPTT of 50-70 seconds
3. Heparin for Anticoagulation
- Intermittent IV injection: 8000-10,000 units IV initially then 50-70 units/kg (about 5000-10,000 units) every 4 to 6 hours
- Continuous IV infusion: 5000 units IV injection followed by IV drip of 20,000-40,000 units/24 hour
4. For catheter patency:
- Utilized to prevent clot formation within venous and arterial catheters
- For adults, use 100 units/ml; for infants under 10kg: 10 units/ml; and for children and infants over 10kg: 10-100 units/ml, ensuring enough volume is administered enough to fill the catheter’s lumen.
- Flushing amount and frequency will vary, depending on catheter type and volume. However, peripheral heparin locks are usually flushed every 6 to 8 hours.
The dosage form and strengths of heparin are as follows:
- As heparin lock solution: 1 unit/ml, 2 units/ml, 10 units/ml, 100 units/ml
- As injectable solution: 1000 units/ml, 2500 units/ml, 5000 units/ml, 10,000 units/ml, 20,000 units/ml
- As premixed IV solution: 12,500 units/250ml, 20,000 units/500ml, 25,000 units/250ml, 25,000 units/500ml
Pharmacology of Heparin
- Mechanism of Action of Heparin
- On low doses, Heparin acts on the body by inactivating factor Xa and inhibiting the conversion of prothrombin to thrombin
- On High doses, Heparin acts on the body by inactivating factors IX, X, XI, XII and thrombin and inhibiting conversion of fibrinogen to fibrin.
- An additional action of heparin is that it inhibits the activation of factor VIII.
2. Pharmacodynamics of Heparin
The body’s bleeding time is typically not affected by low doses of heparin unless full therapeutic doses are administered. In that case, activated clotting time, activated partial thromboplastin time, prothrombin time, whole blood clotting time will be prolonged as after effect of heparin treatment.
- Pharmacokinetics of Heparin
- Heparin has a bioavailability of around 22-40%.
- The onset of its effects will depend on the route of administration. It has an immediate effect when given intravenously and takes 20-30 minutes when given via the subcutaneous route.
- The peak plasma time for heparin takes between 2-4 hours.
- Heparin is extensively a protein-bound medication.
- It is partially broken down and metabolized both by the liver and the reticuloendothelial system. Heparin has no known metabolites when broken down by the body.
- Heparin has an average half-life of 60-90 minutes but is longer at higher doses. It is not dialyzable during hemodialysis and is primarily excreted in the urine.
Drug Interactions with Heparin
- Heparin and other oral anticoagulants – Heparin acts on prothrombin time by prolonging it. When heparin is given together with other oral anticoagulants, blood testing for prothrombin time should be extracted at least 5 hours from the last intravenous dose or 24 hours from the last subcutaneous dose of heparin to obtain valid results.
- Heparin and platelet inhibitors – Certain drugs have platelet inhibition properties, (e.g., some non-steroidal anti-inflammatory drugs, anti-malarial, glycoprotein IIb/IIa antagonists) that may otherwise potentiate the effects of heparin, thereby increasing the bleeding risk of the patient. It is recommended to reduce the dosages of either the heparin or the oral anticoagulant to prevent such effects.
- Heparin and antithrombin III (human) – The anticoagulant properties of heparin is potentiated further if antithrombin III treatment is given simultaneously to patients with familial antithrombin III deficiency. Reducing heparin dosages is warranted for these types of patients.
- Other interactions – Protein synthesis inhibitor antibiotics, antihistamines, cardiac glycosides, certain vasodilators, and stimulants may partially interfere with the anticoagulation properties of heparin.
Adverse Effects of Heparin
Associated adverse effects of heparin may include:
- Hemorrhage, or uncontrolled bleeding in the body
- Heparin-Induced thrombocytopenia (HIT) and Heparin-Induced thrombocytopenia and thrombosis, usually delayed reaction
- Heparin resistance
- Mild pain and ulcer on the post-injection site (presiding a deep subcutaneous injection)
- Elevations of the liver aminotransferase: aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
- Immune hypersensitivity reaction such as generalized reactions of chills, fever, urticarial, asthma, rhinitis, headache, nausea and vomiting, etc.
- Osteoporosis related to chronic, high-dose usage
Associated adverse effects reported post-approval on the use of heparin include:
- Heparin resistance
- Gasping syndrome in infants due to benzyl alcohol preservative
- Skin necrosis on the post-subcutaneous injection site
- Local issues such as erythema, mild pain, hematoma, or ulceration post deep subcutaneous injection
- Risk for the development of debilitating adverse effects in infants due to benzyl alcohol
- Histamine-like reactions
- Vascular disorders, such as vasospastic reactions (to include episodes of painful, ischemic, and cyanosed limbs)
- Delayed transient alopecia
- Rebound hyperlipemia after stopping heparin therapy
Contraindications of Heparin
Heparin is contraindicated to those with:
- History of pentosane polysulfate-induced thrombocytopenia (HIT), either in the presence or absence of thrombosis
- Uncontrolled, active bleeding (except DIC – disseminated intravascular coagulation)
- Conditions wherein appropriate intervals for testing coagulation cannot be done
- Instances where sodium or chloride administration could be harmful to the patient (only for large volume heparin 2 unit/ml solutions)
- Hypersensitivity to heparin or pork products
Caution should be exercised in administering heparin because of the following:
- Risk factors for bleeding or hemorrhage (e.g., subacute bacterial endocarditis, dissecting aneurysms, spinal anesthesia, hemophilia, liver disease, impaired hemostasis)
- While on heparin therapy, bleeding risks increases especially for women, as well as all individuals over 60 years old. Any instances of falling hematocrit levels, hypotension or any other symptom could indicate a hemorrhagic event needing immediate medical attention. Monitor effectiveness of therapy through the activated partial thromboplastin time (APTT) levels.
- Heparin may extend prothrombin time (PT) levels. With this considered, blood testing for prothrombin time should be extracted at least 5 hours from the last intravenous dose or 24 hours from the last subcutaneous dose of heparin to obtain valid results especially in the presence of in tandem use of oral anticoagulants.
- Geriatric dosing: Lower doses are necessary for patients over 60 years old due to them having enhanced serum levels when compared to other age groups given the same dose.
- Increased potential for fatal medication errors: This is due to some heparin injections prepared as catheter lock-flush products in various concentrations.
- Avoid administration of heparin to neonates, infants, and pregnant or lactating mothers, if it is preserved with benzyl alcohol. Benzyl alcohol has been associated with serious effects, especially in pediatric patients (i.e., gasping syndrome).
- The anticoagulant properties of heparin are potentiated further if given in tandem with anti-thrombin III (human) for patients with anti-thrombin III deficiency. Heparin dose reduction should be done to reduce bleeding risk.
- Increased risk for osteoporosis due to the reduction in the body’s mineral bone density brought about by chronic, high dose use
- Reports of elevated liver aminotransferases (ALT and AST) when using heparin that resolves after discontinuation.
Medical Conditions Associated with the Use of Heparin
- Heparin-induced Thrombocytopenia (HIT). This is a severe immune-mediated response resulting from heparin use due to the development of antibodies to a platelet factor 4-heparin complex. If not addressed efficiently, it may progress to HITT (heparin-induced thrombocytopenia with thrombosis) wherein thrombosis develops in the arteries and veins.
- The development of HIT to HITT through fatal thromboembolic events such as deep vein thrombosis, pulmonary embolism, myocardial infarction, renal arterial thrombosis, skin necrosis, gangrene of the extremities may lead to amputation and death.
- HIT is diagnosed based on clinical manifestations through the confirmation of laboratory tests for the presence of antibodies to heparin or platelet stimulation prompted by heparin therapy. Observing platelet count drops of more than 50% from the patient’s baseline is indicative of HIT.
- The platelet count starts to decrease on the fifth to the tenth day of administering heparin with a threshold of 7 to 14 days for new heparin users but can happen within 24 hours for patients experiencing rapid-onset HIT (e.g., previous heparin use within 3 months).
- Once diagnosed or suspected to have either HIT or HITT, the use of an alternative anticoagulant is necessary. It should be noted that HIT or HITT can occur several weeks after heparin is discontinued.
- Heparin and Thrombocytopenia. Patients on heparin therapy are prone to developing thrombocytopenia with an incident rate of up to 30% that occurs between 2 to 20 days (average of 5 to 9 days).
- Obtaining baseline platelet count before heparin therapy is advised. Mild thrombocytopenia (characterized by platelet count of greater than 100,000/mm3) may continue to be stable or corrected even with sustained heparin therapy.
- In light of this, it is prudent to monitor thrombocytopenia once platelet counts fall below 100,000/mm3, to discontinue current therapy, assess for developing HIT or HITT, and use alternatives to heparin.
- Heparin and Heparin Resistance. Heparin resistance may be observed in the following patients with:
- anti-thrombin deficiencies
- elevated heparin clearance in the body
- increased heparin-binding proteins
- increased factor VIII and/or fibrinogen requiring > 35,000 units/24 hours to sustain therapeutic aPTT levels
- fever with attributed thrombosing properties (e.g., thrombophlebitis, myocardial infarction, cancer, post-surgical patients)
For such instances, monitoring for anti-thrombin levels is warranted with associated dose adjustments and periodic testing to ensure therapeutic levels are maintained.
- Heparin and Hypersensitivity. Hypersensitivity reactions such as the presence of chills, fever, and urticarial rash(most common) to asthma, rhinitis, and anaphylactic reactions (most unusual) have been associated with heparin use.
- Allergic reactions happen due to the presence of sulfite as a heparin preservative. In addition, certain preparations (such as heparin sodium in sodium chloride injection), should be cautiously administered to patients with known allergies to pork products for these preparations are derived from animal tissue.
- Patients with known hypersensitivity should only be given heparin if the benefits outweigh the risks, clearly in life-threatening situations.
- Heparin and Hyperkalemia. Heparin has been associated to suppress the secretion of aldosterone that may lead to hyperkalemia. This is particularly true for patients with diabetes, chronic renal failure, pre-existing metabolic acidosis, elevated serum potassium, and intake of potassium-sparring drugs. Hyperkalemia risks increase with the duration of therapy but can be changed once heparin is stopped.
- Ensure that serum potassium is monitored while on heparin therapy, obtaining baseline data prior to initiation, especially for sessions lasting more than 5 days.
Pregnancy and Heparin
The following are the pharmacology of Heparin during pregnancy and lactating mothers, including animal data.
- There were no available data on Heparin injection use and pregnant mothers of associated major birth risks such as defects and miscarriages. In other published reports, exposure to heparin during pregnancy shows no evidence of increased risk for adverse effects for both the mother and fetus.
- In pregnant rats and rabbits in which 10 times, the maximum recommended human dose were administered (around 45,000 units/day), embryo-fetal death were reported by animal reproduction studies. With these, careful consideration should be emphasized regarding benefits versus risks for maternal administration of heparin injections.
- There is no information regarding the presence of heparin in human breast milk due to its relatively large molecular weight, thus preventing it from being excreted via breast milk. However, weighing the risk and benefits of maternal administration to the breastfed infant should be considered.
- Benzyl alcohol-free heparin is recommended during lactation to prevent the maternal transfer from breast milk towards the infant.
- There are no known negative effects of benzyl alcohol, a preservative in parenteral heparin, to the fetus when administered through the mother. However, serious negative effects, even death, have been established when administered intravenously to neonates and infants.
Nursing Care Plan for Patients on Heparin
|Heparin Nursing Interventions||Rationale|
|Assess the patient for signs and symptoms of pulmonary embolism, vein thrombosis, atrial fibrillation with embolization, and/or DIC.||To confirm the indication for administering heparin.|
|Check the patient’s allergy status.||Alternatives to heparin should be considered in case of allergy.|
|Assess if the patient is pregnant.||Heparin belongs to pregnancy category C. Pregnant women may use low molecular weight heparin (LMWH) because this does not cross the placenta and will therefore cause no harm to the fetus. Heparin is used for pregnant women with high risk of clot formation, or already has a history of such during a previous pregnancy.|
|Assess the patient’s current understanding of the medication.||To check for any misconceptions about the drug. To ensure that the patient fully understands what heparin is, its purpose, and how it is administered.|
|Check the patient’s coagulation status.||The patient’s heparin dose should be regularly checked and adjusted according to the results of recent coagulation tests.|
|Check for current medications that include anticoagulants as these should be used cautiously with heparin.||Heparin increases a patient’s risk for bleeding and should be used cautiously in patients who are taking anticoagulants.|
Nursing Planning and Intervention
|Heparin Nursing Interventions||Rationale|
|Administer heparin as prescribed, taking in consideration the most recent coagulation test results.||To ensure medicine compliance and lower the risk for bleeding to develop.|
|Avoid giving intramuscular injections to the patient once heparin therapy has started.||Heparin increases the risk of hematoma formation.|
|If incorporating heparin to intravenous infusion, mix the combined solution well.||To ensure that all of the prescribed heparin dose will be given to the patient.|
|Avoid adding heparin to the infusion lines of other medications, or piggybacking other drugs into the line used for heparin therapy.||To ensure patient safety.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking heparin. Allow time for the patient to ask questions about the drug.||To inform the patient on the basics of heparin.|
|Advise the patient to report any headache, episode of nosebleed (epistaxis), chills, or a feeling of nausea or episode of vomiting.||Nausea and vomiting, headache, episode of nosebleed (epistaxis), chills are signs and symptoms of adverse effects of heparin therapy which render the medical team to immediately respond to resolve these issues related to heparin.|
|In case of heparin poisoning, administer activated charcoal as prescribed.||Activated charcoal is effective in absorbing the salicylate from the stomach to prevent further absorption.|
|Heparin Nursing Interventions||Rationale|
|Ask the patient to repeat the information about heparin, such as the right dose and indication.||To evaluate the effectiveness of health teaching on heparin.|
|Monitor the patient’s coagulation and blood count.||To ensure that the heparin did not cause any heparin-induced thrombocytopenia.|
|Monitor the patient’s response to heparin.||To check if heparin is effective or if another type of anticoagulant is needed.|
|Routinely check for signs and symptoms of bleeding.||Excessive heparin can cause bleeding.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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