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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is managing the care of a client who is receiving a continuous intravenous (IV) infusion of unfractionated heparin for the treatment of a pulmonary embolism. Which of the following actions should the nurse take to ensure the safe administration and monitoring of this parenteral therapy? Select all that apply.

  1. Maintain the continuous heparin infusion on a programmable electronic IV pump.Answer
  2. B
    Connect secondary IV intermittent infusions to the heparin line without consulting a compatibility reference.
  3. Ensure that protamine sulfate is readily available on the nursing unit.Answer
  4. D
    Calculate weight-based infusion rate adjustments using an estimated client weight provided by the family.
  5. Monitor the client's activated partial thromboplastin time (aPTT) at regular prescribed intervals.Answer
  6. F
    Interpret a sudden increase in resting heart rate and a narrowing pulse pressure as an expected response to the infusion.

Answer

The correct actions include maintaining the heparin on an electronic infusion pump, keeping protamine sulfate available, and monitoring aPTT levels.
Safe administration of a high-alert continuous heparin infusion requires strict control of the infusion rate via an electronic pump, serial monitoring of coagulation studies (aPTT) to guide titration, and immediate access to the specific reversal agent (protamine sulfate) in case of overdose or severe hemorrhage.

Step-by-Step Solution

1
Identify the high-alert status of the medication.
Unfractionated heparin is a high-alert anticoagulant with a narrow therapeutic index and a high risk for causing significant patient harm (hemorrhage) if administered incorrectly.
Recognizing the medication's risk level dictates the need for stringent parenteral safety protocols, including exact dosing and dedicated electronic pumps.
2
Evaluate parenteral administration requirements for continuous infusions.
Safe administration requires an exact measured weight in kilograms for dosing, the use of a programmable pump to prevent free-flow, and strict verification of IV compatibility before attaching secondary lines.
Medmath calculation errors based on estimated weights and IV incompatibilities are leading causes of preventable adverse events in parenteral therapy.
3
Determine appropriate ongoing clinical monitoring and emergency preparedness.
The nurse must monitor aPTT levels to titrate the infusion, keep the antidote (protamine sulfate) available, and assess for subtle signs of internal bleeding (such as tachycardia and narrowing pulse pressure).
Proactive monitoring ensures the therapy remains within the therapeutic range and allows for rapid intervention if life-threatening hemorrhage occurs.

Key Concept

Safe parenteral administration and monitoring of continuous high-alert anticoagulant therapy (heparin).
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Topics

Pharmacological and Parenteral Therapies

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