chapter 12

Contamination Risks

Bacterial growth potential, multiple needle entries increase contamination risk, risk of cross-contamination between patients, compromised sterility over time.

Safety Concerns

Incorrect medication concentration, drug stability changes, improper storage conditions, risk of medication errors.

Required Safety Measures

Clean rubber stopper before each entry, use sterile needle/syringe each time, check expiration date, label vial with date opened, store according to manufacturer guidelines, discard if sterility questioned.

Best Practices

Single-patient use when possible, document lot numbers, follow facility protocols, clean workspace for preparation, double-check calculations, use appropriate needle size, maintain aseptic technique.

Prevention Strategies

Regular staff education, proper disposal protocols, clear labeling systems, regular medication audits, quality control checks.

Low Molecular Weight Heparin (LMWH)

Higher bioavailability, longer half-life (up to 6x longer), less protein/tissue binding, predictable plasma levels, fixed dosing possible, once or twice daily dosing, no routine monitoring needed, preferentially inactivates factor Xa, less effective at inactivating thrombin, subcutaneous administration, can be given at home.

Unfractionated Heparin

Lower bioavailability, shorter half-life, high protein/tissue binding, variable plasma levels, requires dose adjustment, continuous or multiple daily doses, requires aPTT monitoring, equal inactivation of factor Xa and thrombin, more complex binding mechanism, IV/SC administration, typically hospital-administered.

Clinical Implications of LMWH

LMWH preferred for DVT prevention/treatment, LMWH allows outpatient management, Heparin requires closer monitoring, both activate antithrombin, both reversible with protamine, LMWH has more predictable response.

Primary Indications for Anticoagulant Therapies

Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Atrial Fibrillation, Acute Myocardial Infarction, Open Heart Surgery, Renal Dialysis, Post-operative Prevention.

Specific Clinical Situations for Anticoagulant Use

Pregnancy (Heparin preferred), Disseminated Intravascular Coagulation, Massive DVT, Stroke Prevention, Extracorporeal Circulation.

Treatment Selection Factors

Need for rapid onset, duration of therapy, patient compliance, monitoring requirements, risk of bleeding, concurrent conditions, cost considerations.

Preventive Uses of Anticoagulants

Post-surgical prophylaxis, high-risk patient prevention, extended prophylaxis, mechanical valve replacement, chronic atrial fibrillation.

Monitoring Requirements for Anticoagulants

INR for warfarin, aPTT for heparin, regular assessment of bleeding risk, periodic lab monitoring, drug-specific protocols.

Administration Technique for SQ Anticoagulants

Use 26-27 gauge, ½-inch needle, select abdomen as preferred site, maintain 2-inch distance from umbilicus, insert at 90-degree angle, rotate injection sites, maximum volume 1 mL per injection, do not massage site after injection.

Required Equipment for SQ Anticoagulants

Appropriate syringe (not insulin), alcohol swabs, clean gloves, sharps container, documentation materials.

Key Safety Points for SQ Administration

Verify correct medication concentration, double-check dosage calculations, assess injection site, monitor for hematoma, document site location, record time of administration, watch for adverse reactions.

Patient Teaching for SQ Anticoagulants

Explain procedure, discuss site rotation, report unusual bleeding, watch for bruising, maintain activity restrictions, follow-up appointments, signs/symptoms to report.

Documentation for Anticoagulant Administration

Medication given, dose/site/time, patient response, teaching completed, next dose due.

Nursing Interventions for Heparin Therapies

Check aPTT or anti-factor Xa.

aPTT or anti-factor Xa levels

Check every 6 hours

CBC, platelet counts

Monitor regularly

Bleeding signs/symptoms

Assess for presence

INR

Track when transitioning to warfarin

Renal and liver function

Monitor continuously

Drug interactions

Check for potential issues

Weight-based protocols

Use for administration

Facility heparin protocols

Follow during administration

IV administration

Implement properly

Document all doses

Accurately record administration

Lab results

Verify before dose changes

Doses calculation

Calculate carefully

Minimize invasive procedures

Bleeding prevention strategy

Soft toothbrush

Use to prevent gum bleeding

IM injections

Avoid to reduce bleeding risk

Pressure to puncture sites

Apply to prevent bleeding

Monitor stool/urine color

Assess for signs of bleeding

Patient education

Recognize bleeding signs

Unusual symptoms

Report immediately

Medication purpose

Understand for compliance

Dietary restrictions

Review with patient

Monitoring importance

Explain to patient

Early ambulation

Encourage for recovery

Elevate affected limbs

To reduce swelling

HIT monitoring

Monitor for heparin-induced thrombocytopenia

Reversal agents

Have available for emergencies

Document interventions

Record all care provided

Fall precautions

Maintain to prevent injuries

Vital signs

Check regularly

Neurological status

Monitor for changes

Pain levels

Assess frequently

Adverse reactions

Watch for during treatment

Fluid balance

Track throughout care

Patient response documentation

Record how patient reacts

Prefilled syringes

Use for Lovenox administration

Injection site

Select abdomen, 2 inches from umbilicus

Air bubble from syringe

Do not expel

Skin fold

Pinch gently before injection

Needle insertion

Insert at 90-degree angle

Injection speed

Inject slowly

Skin fold release

Release after injection

Site rubbing

Do not rub after injection

Weight-based dosing

Use for Lovenox administration

Dosing schedule

Once or twice daily

Anti-Xa levels

Monitor if needed

Prophylaxis dose

40mg daily

Safety measures

Verify correct dose before administration

Injection site monitoring

Check for complications

Site rotation

Rotate injection locations

Bleeding monitoring

Watch for signs of bleeding

Bruising/hematoma

Monitor for development

Platelet counts assessment

Check regularly

Self-injection technique

Educate patients on proper methods

Storage requirements

Explain to patients

Activity restrictions

Inform patients about limitations

Follow-up appointments

Schedule for ongoing care

Seek help

When to contact healthcare provider

Dose documentation

Record dose administered

Site location documentation

Record site used for injection

Time of administration

Document when given

Teaching completion

Document educational discussions

Next dose due

Record when next dose is scheduled

Concentration to mL/hr calculation

Formula: Amount/Volume x mL/hr

Desired dose formula

Desired dose (units/hr) ÷ Concentration (units/mL) = mL/hr

Step-by-step process for calculation

Identify desired dose, determine concentration, divide

Example calculation

Desired: 1180 units/hr, Solution: 100 units/mL, Result: 11.8 mL/hr

Common concentrations

Heparin 25,000 units/250mL = 100 units/mL

Heparin 25,000 units/500mL

Concentration = 50 units/mL

Heparin 20,000 units/500mL

Concentration = 40 units/mL

Facility protocol verification

Always verify before administration

Double-check calculations

Ensure accuracy in dosing

Concentration documentation

Document concentration used

Patient response monitoring

Monitor for any changes

Adjustment based on aPTT results

Modify doses as necessary

Weight-based dose calculation

Ordered dose x patient weight

Ordered dose formula

Ordered dose (units/kg) × Patient weight (kg) = Total dose (units)

Calculation steps

Verify ordered dose, obtain weight, multiply

Example of weight-based dosing

Ordered: 30 units/kg, Patient: 59 kg, Result: 1770 units total dose

Body weight usage

Use actual body weight unless specified

Rounding protocol

Round per facility protocol

Calculation rechecking

Recheck calculations for accuracy