Sherpath: Heparin and Warfarin

A patient asks if it is safe to take heparin while pregnant. How should the nurse respond? A. "Heparin can be administered safely during pregnancy because it does not cross the placenta." B. "Warfarin is a better choice and the nurse will speak with the health care provider about this." C. "Heparin is safe because it will ensure mother and fetus do not develop further blood clots." D. "Heparin will dissolve the blood clot, and it is safe to use this during pregnancy."

A. "Heparin can be administered safely during pregnancy because it does not cross the placenta." Heparin does not crass the placenta; therefore it can be safely administered during pregnancy.

A patient is overheard telling a family member, "I am receiving heparin intravenously to dissolve the blood clot in my lung." What would be an appropriate response to this patient's statement? A. "Heparin does not dissolve clots, but prevents new clots from forming." B. "Heparin will help dissolve your current blood clot." C. "You are receiving heparin subcutaneously, not intravenously for your lung blood clot." D. "You are taking warfarin, not heparin to dissolve your blood clot."

A. "Heparin does not dissolve clots, but prevents new clots from forming." This statement accurately describes the pharmacodynamics of IV heparin therapy.

A 30-year-old woman taking warfarin has a hematocrit of 22. Which questions would be important for the nurse to ask? A. "How heavy is your menstrual bleeding?" B. "Do you have tar-colored stools?" C. "Are you taking any over-the-counter medications?" D. "Are you eating a lot of aged cheeses and meats?" E. "Do you experience headaches frequently?"

A. "How heavy is your menstrual bleeding?" Menstrual bleeding may indicate a reason for the low hematocrit. B. "Do you have tar-colored stools?" Tar-colored stools may indicate a reason for the low hematocrit (GI bleeding). C. "Are you taking any over-the-counter medications?" Over-the-counter medications interact with warfarin and may cause bleeding, which is a reason for the low hematocrit.

Which statement would indicate a patient needs more discharge teaching related to warfarin? Select all that apply. A. "This medication will break up blood clots I have in my legs." B. "I'll take this medication whenever I don't take my baby aspirin." C. "I'll increase my intake of green leafy vegetables." D. "I'll notify my health care provider if I'm considering taking a new over-the-counter vitamin." E. "I'll look for blood in my urine and stool and notify my health care provider if I see this."

A. "This medication will break up blood clots I have in my legs." Warfarin does not break up blood clots. It prevents them from becoming larger and from new ones forming. B. "I'll take this medication whenever I don't take my baby aspirin." Warfarin needs to be taken consistently (every day) and unless directed by the health care provider, should not be taken with aspirin. C. "I'll increase my intake of green leafy vegetables." Warfarin interacts with caffeine and green leafy vegetables and intake should be kept consistent, but not increased.

The nurse is giving discharge teaching regarding warfarin to a Chinese patient. The patient uses coining (rubbing a coin vigorously along the back) to help decrease fever. Which teaching will be especially important for this patient? A. "Warfarin causes an increased risk for bruising, so coining can lead to bruising and would not be advised." B. "It is okay to use coining, as long as you only do it only once a week." C. "You should not use coining because it may increase your INR levels." D. "You can continue coining daily and taking aspirin until the fever is gone."

A. "Warfarin causes an increased risk for bruising, so coining can lead to bruising and would not be advised." Coining can lead to bruising, which is not recommended in warfarin therapy.

Warfarin binds with which molecule in the body? A. Albumin B. Platelets C. Keratin D. Ferritin

A. Albumin Ninety-nine percent of warfarin binds to albumin.

For which patient would warfarin be contraindicated? A. An alcoholic patient with liver disease. B. A patient 24 hours post-operative for total knee replacement C. A patient on hemodialysis at high risk for thrombosis D. A patient with new onset atrial fibrillation who has a mechanical heart valve

A. An alcoholic patient with liver disease. Patients with liver disease do not produce clotting factors and are at high risk for bleeding.

A patient is receiving a continuous heparin infusion. What is the appropriate aPTT response? A. An increase of 1.5-2.5 times above baseline aPTT. B. A decrease of 1.5-2.5 times below baseline aPTT. C. No response. This is not the lab value monitored for continuous heparin infusion. D. An increase in INR 1.5-2.5 times above baseline.

A. An increase of 1.5-2.5 times above baseline aPTT. An increase of 1.5-2.5 times above baseline aPTT is an appropriate aPTT response.

Heparin combines with which factor to inhibit thrombus formation? A. Antithrombin III B. Factor I C. Prothrombin Factor II D. Factor VII

A. Antithrombin III Antithrombin III leads to inactivation of thrombin and prevents thrombus formation.

What is the initial intervention for a patient on an anticoagulant who cuts himself? A. Apply direct pressure with a clean cloth to the cut for 5-10 minutes. B. Call 911 and discuss the situation with the operator. C. Apply a tourniquet above the cut. D. Stop the anticoagulant immediately.

A. Apply direct pressure with a clean cloth to the cut for 5-10 minutes. Applying pressure to the wound should be performed initially for a patient on an anticoagulant who cuts himself.

Which teaching is important for a patient taking warfarin? Select all that apply. A. Avoid herbal products. B. Wear support hose. C. Avoid smoking. D. Avoid exercise. E. Take the warfarin dose at any time.

A. Avoid herbal products. Herbal products interact with anticoagulants and could cause an increase in bleeding. B. Wear support hose. Wearing support hose will reduce venous stasis, which will reduce the risk of thrombosis. C. Avoid smoking. Smoking increases the metabolism of warfarin, which may interfere with the drug's effectiveness.

A patient who only speaks Spanish is being discharged home on an anticoagulant. How can the nurse best ensure the patient understands discharge instructions? A. By providing discharge teaching instructions in the patient's preferred language B. By teaching the patient and using their family member as the interpreter C. By giving the patient written instructions D. By speaking to the patient slowly and enunciating in English the discharge instructions

A. By providing discharge teaching instructions in the patient's preferred language This will better ensure the patient understands the discharge instructions.

The nurse is hanging a new bag of intravenous heparin and sees the dose is prescribed in milligrams. What is the nurse's next action? A. Contact the prescriber for a change in prescription. B. Hang the new bag of heparin, per hospital policy. C. Discuss the situation with the charge nurse. D. Convert milligrams to grams and hang the new bag, per hospital policy.

A. Contact the prescriber for a change in prescription. Heparin is always dosed in units. This is a medication error and needs to be corrected before being administered to the patient.

During the patient interview, the nurse finds that the patient taking warfarin eats a salad for lunch every day. What is a concern for this patient? A. Decrease in warfarin's effectiveness B. Increase in warfarin's action C. Allergic reaction to warfarin D. Increase in GI upset

A. Decrease in warfarin's effectiveness Foods high in vitamin K, such as green, leafy vegetables, can decrease the effectiveness of warfarin.

A patient taking warfarin states she is having trouble falling asleep at night. Which advice would be contraindicated in this patient? A. Drink a cup of chamomile tea before bedtime. B. Drink a cup of warm milk at bedtime. C. Try gentle yoga or meditation two hours before bedtime. D. Drink hot water with honey before bedtime.

A. Drink a cup of chamomile tea before bedtime. Chamomile can affect the INR.

Why is heparin administered parenterally rather than orally? A. Heparin is destroyed by gastric secretions. B. One of heparin's adverse effects is oral lesions. C. Heparin is poorly tolerated and causes nausea. D. Heparin causes bleeding in the GI tract after oral administration.

A. Heparin is destroyed by gastric secretions.

A patient with recurrent blood clots is taking warfarin at home. During an office visit, which lab work would indicate a high risk for thrombus formation? A. INR of 1.5 B. aPTT of 70 C. Platelets 200,000/microL D. INR of 5

A. INR of 1.5 INR of 1.5 indicates the INR is sub-therapeutic and at risk for thrombus.

A patient is taking an anticoagulant at home. In which situation should the health care provider be contacted immediately? A. If the patient develop dark, tarry stools B. If the patient has a sore throat and nasal drainage C. If a small bruise appears on the patient's knee after bumping it on a table D. If the patient has a cut from knife, but is able to stop the bleeding after holding pressure

A. If the patient develop dark, tarry stools Dark, tarry stool is a sign of bleeding when taking an anticoagulant.

A patient is admitted with an acute pulmonary embolism (PE). Heparin intravenous (IV) is prescribed. Why is the prescription for IV rather than subcutaneous heparin? A. Immediate onset of action. B. Ease of administration. C. Better absorption. D. IV heparin will dissolve the PE.

A. Immediate onset of action. IV heparin has an immediate onset of action.

Which result is possible if a patient takes St. John's wort and heparin simultaneously? A. Increased bleeding B. Hemorrhage C. Myocardial infarction D. Blood clotting

A. Increased bleeding Many herbal products interact with anticoagulants and may increase bleeding.

A patient taking warfarin is profusely bleeding. He received vitamin K 2 hours ago but continues to bleed. Which prescription should the nurse anticipate? A. Infusion of fresh frozen plasma B. Infusion of heparin C. Administration of aspirin D. Administration of protamine sulfate

A. Infusion of fresh frozen plasma Infusing fresh frozen plasma is the next step in stopping the bleeding.

What is a critical nursing assessment in a patient receiving a continuous heparin infusion? A. Monitoring the aPTT and notifying the provider of the need to make changes B. Monitoring the INR and notifying the provider of the need to make changes C. Monitoring the patient's platelet count D. Assessing for bruising or bleeding after a fall

A. Monitoring the aPTT and notifying the provider of the need to make changes This is the highest priority when monitoring a patient on a heparin infusion.

Which discharge teaching is appropriate to give a patient who has been prescribed warfarin? Select all that apply. A. Notify the health care provider for excessive bruising, abdominal pain, or tar-colored stools. B. Check with the health care provider prior before taking any new medications. C, Obtain emergency care for profuse bleeding. D. Wear a medical alert ID that states you are taking warfarin. E. There are no dietary restrictions while taking warfarin. F. The medication may cause dizziness.

A. Notify the health care provider for excessive bruising, abdominal pain, or tar-colored stools. These are signs of bleeding. B. Check with the health care provider prior before taking any new medications. Many new medications, especially over-the-counter medications, can interact with warfarin. C. Obtain emergency care for profuse bleeding. Treatment is needed emergently for uncontrolled bleeding. D. Wear a medical alert ID that states you are taking warfarin. In case of an accident, it is important for medical providers to know if a patient is taking warfarin.

A hospitalized patient has been receiving subcutaneous heparin every twelve hours. The patient is scheduled to have a lumbar puncture at 0900. What is the nurse's priority action? A. Notifying the health care provider the patient is receiving heparin. B. Ensuring that the patient understand, and has a consent for the procedure. C. Giving the 0900 dose at 0830 to ensure the patient receives heparin before the lumbar procedure. D. Anticipating what supplies are needed for the 0900 lumbar puncture.

A. Notifying the health care provider the patient is receiving heparin. The health care provider needs to know when the patient last received heparin because the patient is at increased risk for bleeding and hematoma development during the puncture if receiving heparin.

Why should patients inform their dentist if they are taking an anticoagulant? A. Patients are at an increased risk for bleeding. B. Anticoagulants may influence the anesthetic the dentist may use. C. The dentist should know about every medical condition. D. Dentists cannot work on patients taking anticoagulants.

A. Patients are at an increased risk for bleeding. Dental procedures can cause trauma in the oral cavity and lead to bleeding.

For which patients is warfarin contraindicated? A. Patients who are pregnant B. Patients scheduled for brain surgery C. Patients with vitamin K deficiency D. Patients with a mechanical heart valve E. Patients on hemodialysis

A. Patients who are pregnant Pregnancy is a contraindication for patients taking warfarin. B. Patients scheduled for brain surgery Surgery is a contraindication for patients taking warfarin. C. Patients with vitamin K deficiency Vitamin K deficiency is a contraindication for patients taking warfarin.

When assessing a patient who is taking warfarin, which manifestation could indicate bleeding? A. Petechiae on arms B. Pain and burning with urination C. Clay-colored stools D. Elevated blood pressure

A. Petechiae on arms Petechiae (small red spots on the skin) are a sign of bleedin

A patient is receiving heparin infusions for several days after major surgery. In reviewing lab data, the nurse finds that the platelet count is 130,000/microL, when previously it had been 300,000/microL. What might this decrease in platelets signify? A. Possible heparin induced thrombocytopenia (HIT) B. An expected response to heparin therapy C. Bleeding at the surgical site D. Decrease in vitamin K activity

A. Possible signs of HIT include a decrease in platelets 5-10 days after heparin therapy, a decrease in platelet count 30-50% from baseline, and new onset thrombosis.

What is the primary use for subcutaneous heparin therapy? A. Preventing thrombosis B. Managing hepatitis side effects C. Treating myocardial infarction (MI) D. Treating deep vein thrombosis

A. Preventing Thrombosis

What is the antidote to heparin? A. Protamine sulfate B. Vitamin K C. Packed red blood cells D. Whole blood

A. Protamine sulfate is the antidote to heparin.

Which laboratory value should the nurse monitor related to warfarin therapy? A. Prothrombin time reported in international normalized ratio (INR) B. Activated prothrombin time (aPTT) C. White blood cell count (WBC) D. Hematocrit (Hct) and hemoglobin (Hgb)

A. Prothrombin time reported in international normalized ratio (INR)

A patient is administering subcutaneous heparin at home. Which teaching point is appropriate for this patient? A. Shave with an electric razor. B. Inject heparin in the same spot every day. C. Dispose of used syringes in the regular garbage. D. Use a hard-bristled toothbrush.

A. Shave with an electric razor. An electric razor should be used because there is less risk for cutting himself than when using a straight r

Which teaching is appropriate for a patient taking warfarin? Select all that apply. A. Use an electric razor. B. Use a soft-bristled toothbrush. C. Notify your dentist you are taking warfarin. D. Take aspirin whenever you need for a headache. E. Use over-the-counter supplements as needed.

A. Use an electric razor. Using an electric razor decreases the risk of bleeding. B. Use a soft-bristled toothbrush. Using a soft-bristled toothbrush decreases the risk of bleeding. C. Notify your dentist you are taking warfarin. Notifying the dentist of warfarin use is appropriate teaching

Which laboratory value should the nurse monitor related to intravenous (IV) heparin therapy? A. aPTT B. INR C. Platelets D. CBC

A. aPTT is the priority lab value and guides IV heparin therapy decisions.

A patient is started on a continuous infusion of heparin at 0900. What time should an aPTT be checked? A. 1000-1200 B. 1300-1500 C. 1700-1900 D. 2100-2300

B. 1300-1500 The time to check aPTT after the initial infusion is started is 4-6 hours.