A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply.

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Quizplus · Accepted Answer

Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). (Option A) Continuing the heparin infusion will put the client at risk for a severe bleeding episode. (Option B) Vitamin K is the reversal agent for warfarin. (Option C) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client's bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent. Educational objective: The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.

A Client Is Receiving a Continuous Heparin Infusion and the Most