Which nursing diagnosis would be possible for a client receiving intravenous heparin therapy?

• A. Potential for fluid volume excess
• B. Potential for pain
• C. Risk for injury
• D. Potential for body image disturbance

Answer: (C)

Anticoagulant therapy with intravenous heparin increases the risk for bleeding, which can lead to injury. Heparin inhibits clot formation, so even minor trauma or routine activities can result in significant bleeding or bruising. That makes Risk for injury the most appropriate nursing diagnosis for a client on IV heparin. The nurse should monitor for signs of bleeding (gum or occult bleeding, bruising, blood in urine or stool, severe headache with neck stiffness, etc.), regularly check therapeutic labs (such as aPTT or anti-Xa levels) to keep the anticoagulation in range, and implement bleeding precautions (no IM injections, use a soft toothbrush and electric razor, minimize needle sticks). Other options don’t align with the main issue here, since fluid volume excess, pain, and body image disturbance aren’t primary risks specifically associated with heparin therapy.