Anti-Coagulation Record Form printable pdf download

ANTI -

COAGULATION

RECORD

PATIENT IDENTIFICATION

DETERMINE DOSING WEIGHT

1. Actual Body Weight (ABW) _____________ lbs

Height __________ ft __________ inches

Weight in lbs ÷ 2.2 =

_____________ kg

2. Calculate Ideal Body Weight (IBW) using the number of inches above / below 5 feet. For example, if the

patient's height is 4ft 5in, use "7" as the difference in inches. If the patient's height is 5ft 7in, use "7" as the

difference in inches. If the patient's height is 6ft 2in, use "14" as the difference in inches.

= 50kg + (2.3kg x # of inches > or < 5 feet)

FEMALE: = 45kg + (2.3kg x # of inches > or < 5 feet)

MALE:

= 50kg + (2.3kg x ________ inches)

= 45kg + (2.3kg x ________ inches)

If > 5 ft =

= 50 kg + ________ kg

= 45 kg + ________ kg

or, if < 5 ft =

= 50 kg - ________ kg

or, if < 5 ft =

= 45 kg - ________ kg

IBW = ________ kg

3. Compare ABW__________ and IBW__________ : If ABW < IBW, use ABW as dosing weight.

4. If ABW > IBW, use the following equation

Dosing Weight

= IBW + 0.3 ( ABW - IBW )

Subtract actual body weight with ideal body weight.

= ________ kg + 0.3 ( ________ kg - ________ kg )

= ________ kg + 0.3 ( ________ kg )

= ________ kg + ________ kg

Dosing Weight

= ________ kg

1. INITIAL BOLUS: 75 units x _____________ Kg (dosing weight) = _____________ units.

Convert units to ml by dividing __________ units by 1000ml = __________ (round to nearest 10th of ml)

Actual Dosage rounded to nearest 10th of ml = __________ml

_____________ Units Heparin Bolus Given

Time Given _____________

2. HEPARIN INFUSION:

20,000 units Heparin in 500ml Normal Saline.

This is equal to 40 units of Heparin per ml (500 ÷ 20,000 = 40 units / ml)

Initial infusion: 18 units x __________ kg (dosing weight) / hour

___________ units / hour

3. Convert units of Heparin to ml/hr. Divide units/hr by 40 units/ml. This is your Initial Infusion Rate.

Initial Infusion Rate = __________ units / hour ÷ 40 units / ml

Initial Infusion Rate = __________ ml / hr. (round to the nearest ml)

4. Calculate the ACTUAL UNITS of Heparin currently infusing by multiplying rate x 40 units / ml.

_______ (initial infusion rate) x 40 units / ml = _______________ ACTUAL UNITS

SIGNATURES / DATE / TIME

NURSE'S SIGNATURE / TITLE:

DATE / TIME:

NURSE'S SIGNATURE / TITLE:

DATE / TIME:

PART OF THE MEDICAL RECORD

8850023 Rev. 05/05

Anti Coagulation Record_NURSING

PAGE 1 of 2

Anti-Coagulation Record Form

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