# A 70-year-old client receiving an unfractionated heparin infusion for acute pulmonary embolism has the following labs and assessment: aPTT 90 seconds (institutional therapeutic range 60-80 seconds), no active bleeding, vital signs stable. Per the institutional weight-based heparin nomogram for an aPTT in this range, which order would the nurse anticipate?

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> subject: Adverse Effects/Contraindications/Interactions  
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## Question

A 70-year-old client receiving an unfractionated heparin infusion for acute pulmonary embolism has the following labs and assessment: aPTT 90 seconds (institutional therapeutic range 60-80 seconds), no active bleeding, vital signs stable. Per the institutional weight-based heparin nomogram for an aPTT in this range, which order would the nurse anticipate?

## Option

1. Hold the infusion for 0-30 minutes per nomogram, then resume at a reduced rate (typically 1-2 units/kg/h decrease), and recheck the aPTT in 6 hours. **✔ Correct answer**
2. Continue the current infusion rate without adjustment, as the aPTT of 90 seconds remains within an acceptable range for a pulmonary embolism.
3. Discontinue the heparin infusion permanently, and initiate warfarin therapy with enoxaparin bridging until the INR reaches 2-3.
4. Administer a bolus dose of 5,000 units of unfractionated heparin IV and increase the infusion rate by 2 units/kg/h to achieve a therapeutic aPTT.

**Correct answer: 1**

## Explanation

Heparin nomogram interpretation
Institutional heparin nomograms guide nurse-driven adjustments based on weight and aPTT (or anti-Xa). A common Raschke-type weight-based nomogram (target aPTT 60-80 s):
• aPTT 90 (supratherapeutic): hold for 30-60 minutes, then decrease rate 3 units/kg/h.
• Recheck aPTT 6 hours after every dose change.

Many institutions adapt these ranges; some use anti-Xa (target 0.3-0.7 IU/mL) instead of aPTT in patients with lupus anticoagulant or factor deficiencies.

Based on aPTT 90 (just at the upper edge of supratherapeutic depending on institution), a brief hold AND a rate decrease with re-check in 6 hours is the appropriate response. Independent bolus, permanent discontinuation with aspirin substitution, or no change all violate the protocol.

## In-depth explanation

Clinical reasoning summary
Heparin nomogram interpretation
Institutional heparin nomograms guide nurse-driven adjustments based on weight and aPTT (or anti-Xa). A common Raschke-type weight-based nomogram (target aPTT 60-80 s):
• aPTT 90 (supratherapeutic): hold for 30-60 minutes, then decrease rate 3 units/kg/h.
• Recheck aPTT 6 hours after every dose change.

Many institutions adapt these ranges; some use anti-Xa (target 0.3-0.7 IU/mL) instead of aPTT in patients with lupus anticoagulant or factor deficiencies.

Based on aPTT 90 (just at the upper edge of supratherapeutic depending on institution), a brief hold AND a rate decrease with re-check in 6 hours is the appropriate response. Independent bolus, permanent discontinuation with aspirin substitution, or no change all violate the protocol.

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