Subq Heparin

  1. 0
    I don't know how it is on other Medical floors, but on the medical floor I currently work on the hospitalist group goes extreme with the subq heparin. The big problem with this is we have to scan another nurse before we can even give the heparin to the patient and that takes large amounts of time to hunt down another nurse in the middle of med-pass.

    If I have an ambulatory patient that gets up and uses the bathroom, since heparin is used as a DVT prophlaxsis, I normally talk them out of the shot. Am I wrong for educating my patients on "WHY" they are getting the heparin shot, or should I be talking them into something they don't techincally need. The heparin shots are only given for "DVT prophlaxsis!"
  2. 14 Comments so far...

  3. 4
    I would not talk my pts out of getting the shot, that is putting you at risk should something happen. The pts may get up to go to the bathroom but that is not a lot of movement since most hospitalized pts still spend most of their time in bed or sitting in the chair...
    anotherone, nrsang97, Sunnysidegirl, and 1 other like this.
  4. 1
    I agree, don't talk them out of it for the reasons mentioned above. Patients need to be given the explanation on WHY they are receiving heparin (or lovenox) and the need for DVT prophylaxis. If they refuse, then the they refuse, you can't force them to take it. I have had patients refuse before. I also make sure I document that the "patient was educated on DVT prophylaxis and the purpose of the medication but patient still refused" to cover my butt.

    I don't know how your med scanning works, but for any medicine that requires a cosignature (heparin and insulin), we scan the medication first and then it asks for the cosignature. Because of this, I always give the heparin last so that when I leave the room I can find the nurse who had witnessed my heparin earlier cosign.
    anotherone likes this.
  5. 3
    We do not need a co-sign at the hospital that I work. We just have to make sure it is not given if the pt is due to go to the OR. Keep in mind that there are 20 year old who are at the hospital just to give birth who wind up with a blood clot. Don't play doctor!
    anotherone, loriangel14, and Sun0408 like this.
  6. 7
    Not to sound mean, but are you a doctor or a nurse? If you feel that patient doesn't need the medication, consult with the ordering MD to have it D/C'd. I think you are doing your patients a disservice by talking them out of taking a medication just because you don't want to take the time out to find a second nurse for verification!
  7. 4
    I certainly wouldn't try to talk patients out of something they need just to make your job easier. At the same time, many facilities inappropriately use blanket DVT prophylaxis for all patients with only a small list of contraindications, mainly out of laziness. Subq heparin for VTE prophylaxis carries a risk, 4 severe bleeding episodes per 1,000 patients, many of these result in death, which is one reason it should only be used when actually indicated, which is in patients with limited mobility or on prolonged bedrest and at least one risk factor. An example of a better thought out protocol.

    H
    eparin is considered a high risk med and a double check should be used whenever a dose is measured, which is why double checks don't typically pertain prophylaxis doses which are pre-measured, JC and ISMP consider barcoding to be a sufficient double check for pre-measured doses.
    SC_RNDude, anotherone, Vespertinas, and 1 other like this.
  8. 4
    I would ask the doctor to reassess the patient's heparin order instead of talking them out of it just because finding a cosigner is a pain in the butt.
    anotherone, Vespertinas, nrsang97, and 1 other like this.
  9. 1
    Ok, so using the phrase, "trying to talk my patient out of something" was a tad bit misused. I'm not "TALKING" my patient out of anything. I am after all a nurse as one of you guys sorely pointed out. BUT, it is my job to educate my patient. And if my patient asks me, the nurse, a question as to why they are even getting the heparin, I will reply with the knowledge as to which I was trained and educated with through experience and evidence-based practice.

    The hospitalists here at my facility order subq heparin on EVERYONE they admit and its not pre-measured. It could be a 18 year old ambulatory patient here for cellulitis of the arm and subq heparin would still be ordered. Its not a matter of need, its a matter of the pre-made order sheets that the physicians just check mark.. my opinion of course.

    Having to hunt down a nurse just for verification is a complete pain in my rear, I won't state that any differently. I understand that heparin and insulin are high risk drugs that need another nurse to cosign for safety reasons.

    The physicians at our facility have an option to choose alternative treatments, such as SCDs, then treat everyone that walks into the building with subq heparin.

    I heard that DVT prophlaxsis was going to be the new core-measure this year. Has anyone else heard that?
    anotherone likes this.
  10. 1
    Quote from JTworoger
    Ok, so using the phrase, "trying to talk my patient out of something" was a tad bit misused. I'm not "TALKING" my patient out of anything. I am after all a nurse as one of you guys sorely pointed out. BUT, it is my job to educate my patient. And if my patient asks me, the nurse, a question as to why they are even getting the heparin, I will reply with the knowledge as to which I was trained and educated with through experience and evidence-based practice.

    The hospitalists here at my facility order subq heparin on EVERYONE they admit and its not pre-measured. It could be a 18 year old ambulatory patient here for cellulitis of the arm and subq heparin would still be ordered. Its not a matter of need, its a matter of the pre-made order sheets that the physicians just check mark.. my opinion of course.

    Having to hunt down a nurse just for verification is a complete pain in my rear, I won't state that any differently. I understand that heparin and insulin are high risk drugs that need another nurse to cosign for safety reasons.

    The physicians at our facility have an option to choose alternative treatments, such as SCDs, then treat everyone that walks into the building with subq heparin.

    I heard that DVT prophlaxsis was going to be the new core-measure this year. Has anyone else heard that?
    VTE (venous thromboembolism) is part of the NHQM. We have VTE Prophylaxis as a QM at my hospital, and I think the goal is to have all hospitals have that QM in the future. VTE prophylaxis includes pharmacological (heparin, Lovenox, Coumadin) and mechanical (SCDs, TEDs). Most doctors order both, sometimes one, sometimes none. If a patient refuses pharmacological VTE prophylaxis, we need to get an MD order for mechanical prophylaxis unless of course there is a contraindication.
    loriangel14 likes this.
  11. 0
    Modified Caprini risk assessment model. This can be used to estimate baseline risk for developing VTE in the absence of prophylaxis.



    1 point 2 points 3 points 5 points
    Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
    Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
    BMI >25 kg/m2 Major open surgery (>45 minutes) Family history of VTE Hip, pelvis, or leg fracture
    Swollen legs Laparoscopic surgery (>45 minutes) Factor V Leiden Acute spinal cord injury (<1 month)
    Varicose veins Malignancy Prothrombin 20210A
    Pregnancy or postpartum Confined to bed (>72 hours) Lupus anticoagulant
    History of unexplained or recurrent spontaneous abortion Immobilizing plaster cast Anticardiolipin antibodies
    Oral contraceptives or hormone replacement Central venous access Elevated serum homocysteine
    Sepsis (<1 month) Heparin-induced thrombocytopenia
    Serious lung disease, including pneumonia (<1 month) Other congenital or acquired thrombophilia
    Abnormal pulmonary function
    Acute myocardial infarction
    Congestive heart failure (<1 month)
    History of inflammatory bowel disease
    Medical patient at bed rest
    Interpretation
    Surgical risk category* Score Estimated VTE risk in the absence of pharmacologic or mechanical prophylaxis (percent)
    Very low (see text for definition) <0.5
    Low 1 to 2 1.5
    Moderate 3 to 4 3.0
    High ≥5 6.0
    * This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and reconstructive surgery. See text for other types of surgery (eg, cancer surery). VTE: venous thromboembolism.
    From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines. Chest 2012; 141:e227S. Reproduced with permission from the American College of Chest Physicians. Copyright 2012.


    Lets play with interpretations: one total knee replacement = instant high risk a 65 yo female s/p lap chole, has varicose veins = high risk Overweight female, ulcerative colitis, oral contraceptives, had an ostomy put in 3 days ago (colorectal surgery is instant high risk too) = high ...This is fun. All these patients should be mobile. Medical example: A lot of patients with malignancies are perfectly mobile but go home on Arixtra. Your cellulitis patient may be 65 years old plus that cellulitis can create venous stasis. Virchow's triad, you know?

    This is just one tool to assess a specific population. My point is that while I don't doubt that your residents may be over-prescribing, I'd like to bring to your attention it's also possible you're not aware of the numerous factors that might go into determining a patient's risk.
    Last edit by Vespertinas on Mar 7, '13


Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

A Big Thank You To Our Sponsors
Top