Anti-Coagulation Record Form Page 2
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1
2ANTI - COAGULATION RECORD
APTT RESULT
HEPARIN INFUSION INTERVENTION
< 50
Give a bolus of 75 units/kg. Increase infusion by 4 units / kg / hour.
50 - 70
Give a bolus of 40 units/kg. Increase infusion by 2 units / kg / hour.
71 - 130
Therapeutic Range - NO CHANGE
131-159
Decrease infusion rate by 2 units / kg / hour.
160 - 199
Hold Heparin Infusion for 1 hour; then, decrease infusion rate by 2 units / kg / hour.
> 200
Hold Heparin Infusion for 2 hours; call MD, decrease infusion rate by 4 units / kg / hour.
5. Order an APTT 6 hours after any dosage change. Adjust heparin infusion based on the sliding scale until APTT is
within therapeutic range (71-130).
6. If clinical evidence of bleeding is present, hold heparin infusion and notify physician immediately. If the APTT is
>160, withhold heparin drip for 1 hour, etc. (see table)
D
T
APTT
INTERVENTION
ADJUSTED RATE
BOLUS
I
A
I
Time
N
Increase (I) or Decrease
T
M
Result
Drip
I
Decrease (D) units
= Current Rate ( + or - )
Units x Dosing
E
E
/ Time
Held
T
x kg / hr dosing weight
New Rate
Weight (kg)
( I or D ) __________ Units x
Current rate _______ Units / Hr (+ / -)
__________ Units
Dosing
Dosing
__________ kg
__________ Units / Hr Adjustment
x __________ kg
Weight
Weight
= ________Units / Hour
= __________ Units / Hour
= ________Units / ml ÷ 1000 ml
Adjustment
÷ 40 units / ml = __________ ml / Hr
= ________ml Bolus
( round to nearest ml)
( round to nearest 10th of ml)
Actual dosage = __________ml / Hr
Actual dosage = __________ml
__________ Units Heparin / Hr
__________ Units Heparin
( I or D ) __________ Units x
Current rate _______ Units / Hr (+ / -)
__________ Units
Dosing
Dosing
Dosing
__________ kg
__________ Units / Hr Adjustment
x __________ kg
Weight
Weight
Weight
Weight
Weight
= ________Units / Hour
= __________ Units / Hour
= ________Units / ml ÷ 1000 ml
Adjustment
÷ 40 units / ml = __________ ml / Hr
= ________ml Bolus
( round to nearest ml)
( round to nearest 10th of ml)
Actual dosage = __________ml / Hr
Actual dosage = __________ml
__________ Units Heparin / Hr
__________ Units Heparin
( I or D ) __________ Units x
Current rate _______ Units / Hr (+ / -)
__________ Units
Dosing
Dosing
Dosing
__________ kg
__________ Units / Hr Adjustment
x __________ kg
Weight
Weight
Weight
Weight
Weight
= ________Units / Hour
= __________ Units / Hour
= ________Units / ml ÷ 1000 ml
Adjustment
÷ 40 units / ml = __________ ml / Hr
= ________ml Bolus
( round to nearest ml)
( round to nearest 10th of ml)
Actual dosage = __________ml / Hr
Actual dosage = __________ml
__________ Units Heparin / Hr
__________ Units Heparin
DATE / TIME OF DISCONTINUATION:
REASON FOR DISCONTINUATION:
ADDITIONAL COMMENTS: (Please indicate episodes and treatment of major bleeding)
PART OF THE MEDICAL RECORD
Anti Coagulation Record_NURSING
PAGE 2 of 2
8850023 Rev. 05/05
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