Anticoagulants - Heparin: Nursing pharmacology

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ANTICOAGULANTS: HEPARINS
DRUG NAME	Unfractionated heparin; Low molecular weight heparin (LMWH): enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep)
CLASS	Anticoagulant
MECHANISM OF ACTION	Enhance the activity of antithrombin III → inhibit Factor Xa and Factor IIa (thrombin) → stop coagulation cascade
INDICATIONS	Deep vein thrombosis, pulmonary embolism Ischemic stroke, transient ischemic attack Coronary artery disease Cardiac valve replacement or coronary angioplasty Coagulation disorders like antiphospholipid syndrome and DIC Dialysis Surgical procedures: cardiopulmonary bypass, ECMO, PCI
ROUTE(S) OF ADMINISTRATION	Unfractionated heparin: IV, SubQ LMWH: SubQ
SIDE EFFECTS	Undue bleeding (antidote: protamine sulfate for unfractionated heparin; partially effective for LMWH) Injection site reactions Hyperkalemia Heparin-induced thrombocytopenia (HIT) Osteoporosis
CONTRAINDICATIONS AND CAUTIONS	Active internal bleeding Trauma in the past three months History of intracranial hemorrhage or ischemic stroke Gastrointestinal ulcers Coagulopathies, bleeding disorders Thrombocytopenia History of HIT Antiplatelet and thrombolytic medications (increased risk of bleeding) Allergies to porcine products Hepatic or renal disease Alcohol use disorder

NURSING CONSIDERATIONS for ANTICOAGULANTS: HEPARINS

ASSESSMENT AND MONITORING

Unfractionated heparin, LMWH
Focused baseline assessment

Weight
Vital signs
Laboratory test results; CBC, PTT, aPTT, renal function tests

Administration

Confirm prescribed dose per kg
Double check prescribed dose with a second nurse
Have protamine sulfate readily available
Unfractionated heparin SubQ
- Inject 2 inches or 5 centimeters away from client’s navel
- Pinch the skin slightly
- Insert the needle at a 90 degree angle
- Inject slowly
- Withdraw needle; lightly press the site with dry gauze or an alcohol swab - do not massage the injection site
Unfractionated heparin IV
- Ensure patent IV catheter
- Follow facility protocol
  - Calculate units of heparin / kg / hr
  - Adjust infusion per PTT
Monitor for signs / symptoms of bleeding; clot formation; aPTT; platelets

CLIENT EDUCATION

Purpose of medication

Prevent clot formation

Report

Signs of bleeding; e.g., oozing from the IV insertion site, nosebleed, sudden headache
Signs of clot formation; e.g., new pain, swelling, or warmth in their leg; shortness of breath; sudden onset of confusion, vision changes, trouble speaking, or one-sided weakness

LMWH (e.g., enoxaparin) self-administration

Review appropriate technique for subcutaneous injections using prefilled syringe
Inject the medication once per day, at the same time each day
May feel minor discomfort or slight bruising may occur at the injection site
Teach bleeding precaution; e.g., soft bristled toothbrush, electric razor; avoiding medications that affect platelets, avoiding activities that can cause injuries
Contact healthcare provider for signs of minor bleeding; e.g., bleeding gums, nosebleeds, longer than normal menstrual periods
Seek emergency medical care immediately
- Falls or injuries
- Signs of significant bleeding such as dark urine or stools, coughing up blood, heavy bleeding from a minor cut, or sudden back pain
- Signs of clot formation; new leg pain, swelling, or warmth; shortness of breath; sudden onset of confusion; vision changes; trouble speaking; or one-sided weakness

Transcript

Content Reviewers

Antonella Melani, MD,Lisa Miklush, PhD, RNC, CNS,Gabrielle Proper, RN, BScN, MN

Contributors

Jahnavi Narayanan, MBBS,Rachel Yancey,Jung Hee Lee, MScBMC

Anticoagulants are medications that work by interfering with the functional clotting factors in the coagulation cascade, and are used to prevent the formation of thrombi, or blood clots, and are used to prevent or treat thromboembolic events, such as deep vein thrombosis, pulmonary embolism, ischemic stroke, transient ischemic attack, coronary artery disease or myocardial infarction.

They're also used in clients with coagulation disorders, including antiphospholipid syndrome and disseminated intravascular coagulation; as well as in clients who underwent cardiac valve replacement or coronary angioplasty; and during surgical procedures like cardiopulmonary bypass, percutaneous coronary intervention, extracorporeal membrane oxygenation, and in clients undergoing dialysis.

Among the most important anticoagulants are heparins. These include unfractionated heparin, which is derived from porcine sources, and can be administered intravenously or subcutaneously; as well as low molecular weight heparins or LMWHs, which are synthetic analogs of certain portions of the heparin molecule. These include enoxaparin, dalteparin, and tinzaparin, and are given subcutaneously.

Once administered, heparins work by binding to and enhancing the activity of antithrombin III, which is an anticoagulant protein synthesized by the liver.

Sources

"Focus on Nursing Pharmacology" LWW (2019)

"Pharmacology" Elsevier Health Sciences (2014)

"Mosby's 2021 Nursing Drug Reference" Mosby (2020)

"First Aid for the USMLE Step 1 2018, 28th Edition" McGraw-Hill Education / Medical (2017)

"Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)

"Katzung & Trevor's Pharmacology Examination and Board Review,11th Edition" McGraw-Hill Education / Medical (2015)

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Anticoagulants - Heparin: Nursing pharmacology

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