A 68-year-old client complaining of chest pain is admitted t…
A 68-year-old client complaining of chest pain is admitted to the medical-surgical nursing unit for acute coronary syndrome. The cardiologist prescribes a continuous IV heparin infusion per protocol. The client weighs 165lb (74.8 kg), and baseline partial thromboplastin time (PTT) is 32 seconds. A bolus is administered as prescribed and a continuous infusion is initiated based on the below protocol noted in the patients Medication Administration Record. MEDICATION ADMINISTRATION RECORD DATE TIME FOCUS Medication Administration Record April 15, 2025 0700 Infusion Baseline PTT and every 6 or 12 hours after start of continuous infusion based on protocol Heparin 80 units/kg IV bolus prior to start of continuous infusion Start heparin 25,000 units in 250 mL D5W (concentration 100 units/mL) continuous infusion 18 units/kg/hr Adjust continuous infusion based on the following: PTT less than 35 seconds: IV bolus 80 units/kg, in-crease rate by 4 units/kg/hr, PTT in 6 hours PTT 35–45 seconds: IV bolus 40 units/kg, increase rate by 2 units/kg/hr, PTT in 6 hours PTT 46–70 seconds (goal): No bolus, no rate change, PTT in 12 hours PTT 71–90 seconds: No bolus, decrease rate by 2 units/kg/hr, PTT in 12 hours PTT above 90 seconds: No bolus, stop infusion The next day, the oncoming nurse assigned to monitor the client assesses the client and checks laboratory results. The client states, “I feel OK. I just been have a hard time sleeping since I’ve been in the hospital, I really miss my bed. My chest pain is better today than yesterday. I did have a pretty heavy nosebleed this morning, but it stopped a little while ago. I’m ready for breakfast; it should be here soon. I think I heard it’s pancakes and I can smell bacon.” The most recent PTT from 1 hour ago was 96 seconds. The heparin infusion is running at 13.5 mL/hr. Select the three priority needs that are of immediate concern to the nurse.
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