atrial fibrillation
K.N. calls your anticoagulation clinic to report a nosebleed that is hard to stop What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of the INR
A PT (Prothrombin Time) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder. The INR (International Normalized Ratio) test is calculated from a PT result and is used to monitor how well the blood thinning medication, warfarin, is working to prevent blood clots. The expected INR levels for K.N. should be 2.0 to 3.0 1.5-2.0- DVT prophylaxis on Coumadin 2.0-3.0- A-fib 2.5.-3.5- On mechanical valve
When you get the results, his INR is critical at 7.2. What is the danger of this INR level?
An elevated INR of 7.2 indicates that the patient is experiencing a warfarin overdose. The danger of this INR level is excessive bleeding as a result of not being able to form a clot.
What is the purpose of the warfarin (Coumadin) in K.N.'s case
Atrial fibrillation puts patients at increased risk for heart failure, myocardial ischemia, and embolic events such as stroke. The warfarin (anticoagulant, blood thinner) is given prophylactically to prevent strokes.
How does atrial fibrilla differ ion from a normal heart rhythm?
Atrial rate of 300-600 bpm Ventricular rate of 120-200 bpm Highly irregular rhythm No discernible P waves Reduces ventricular filling and reduces cardiac output; clot formation risk
What happened when K.N. began taking the PPI?
By using both Warfarin combined with the PPI, omeprazole, K.N. increased his risk for bleeding. The combination caused an increase in the anti-clotting effect of Warfarin, leading to a prolonged PT/INR, ultimately leading to the nose bleed.
K.N.'s INR the next day is 3.7, and the health care provider makes no further medication changes. K.N. is instructed to return again in 7 days to have another PT/INR drawn. Why should the INR be checked again so soon instead of the usual monthly follow-up
He needs to be checked in order to evaluate if the vitamin K dose is expressing its therapeutic effect of lowering the PT/INR. Remaining at a high risk for bleeding or having too high of a vitamin K dose are dangerous.
You want to make certain K.N. knows what "hold the next dose" means. What should you tell him?
I would tell K.N. that "hold the next dose" means to skip and not take the medication tonight. I would also have him repeat to me the instructions I have provided.
K.N. asks you why his PT/INR has to be checked so soon. How will you respond?
I would tell K.N. that a high level of PT/INR can be dangerous because it can lead to internal bleeding. I would explain the normal range of PT/INR which should be in the range of 2.0-3.0. A high level of PT/INR means that the blood is too thin and a low level of PT/INR means that the blood is too thick. So, K.N. needs to get his PT/INR checked soon to make sure that it is not high because this can lead to excessive bleeding meaning a clot will not be able to form.
What should K.N. have done to prevent this problem with taking the PPI
In order to prevent this problem, K.N. should have spoken to his doctor before taking an over-the-counter medication. His doctor may have given him a different solution to treat his heartburn or he may have allowed him to take the PPI, but would have first adjusted the dosage of these medications and monitored the PT/INR more frequently.
Four months later, K.N. informs you that he is going to have a knee replacement next month. What will you do with this information?
K.N. should stop taking his warfarin a week before surgery. He should get his PT/INR test done before surgery. He should keep contact with his doctor to discuss hsi health. After surgery it is important for K.N. tp take the medicines prescribed by his doctors after surgery. He should continue his dose of anticoagulant prescribed by his doctor. This is important because clot formation is a risk especially in heart patients.
Identify 2 other patient education needs you will stress at this time
The patient needs to understand OTC drugs, food/beverage that interact with warfarin which can increase bleeding. Consult HCP(Grapefruit juice, mangos, acetaminophen, PPI) Refrain from activities that can result in an injury (using razor blades, use waxed dental floss, soft bristle tooth brush, take care using other sharp objects) Med alert bracelet for warfarin
The provider gives K.N. a low dose of vitamin K orally, asks him to hold his warfarin dose that evening, and asks him to come back tomorrow for another prothrombin time (PT) and INR blood draw. Why is K.N. instructed to take the vitamin K
Vitamin k is the antidote for warfarin and will decrease the PT/INR. It plays a role in helping the blood clot and reduce prolonged bleeding.
Compare the duration of action of warfarin (Coumadin) and enoxaparin (Lovenox) and explain the reason the provider switched to enoxaparin at this time.
Warfarin lasts longer (2-5 days) Lovenox more immediate (12 hours) Risk for thrombosis
K.N. tells his doctor, "I saw this commercial for a new blood thinner called Xarelto. I'd like to take that instead because I wouldn't need to have all this blood work done." How do you expect the physician to respond
Xarelto is approved for the use of stroke in patients with a-fib who do not have valve disease and to decrease the risk of clot formation after knee surgery. Research has been conducted that this switch can occur and the recommendation is that Xarelto only be started with the INR is <3.0 and warfarin has been stopped Because of his hx of valve disease with replacement he would not be a candidate
K.N. tells you that he has had a lot of pain in his knee and wants to take ibuprofen (Advil) because it is an over-the-counter product. How do you reply to his request?
You should avoid taking ibuprofen (Advil) while taking warfarin because it may increase your risk of bleeding. An adverse effect of ibuprofen (Advil) is GI bleeding. Better choice: acetaminophen
K.N. grumbles about all of the lab tests but agrees to follow through. You provide patient education to K.N. and start with reviewing the signs and symptoms (S/S) of bleeding. What are potential S/S of bleeding that should be taught to K.N.? Select all that apply a. Insomnia b. Black, tarry stool c. New onset of dizziness d. Stool that is pale in color e. New joint pain or swelling f. Unexplained abdominal pain
b. Black, tarry stool - this is an indication of a GI bleed c. New onset of dizziness - this is a result of oxygen not being carried to the brain e. New joint pain or swelling - this can be the result of bleeding into the joint spaces f. Unexplained abdominal pain - this can be the result of an internal abdominal bleed
Which nursing interventions are appropriate when administering enoxaparin? Select all that apply. a. massage the area after the injection has been given b. hold extra pressure over the site after the injection c. monitor aPTT levels d. the preferred site of injection is the lateral abdominal fatty tissue e. administer via IM injection into the deltoid muscle.
b. hold extra pressure over the site after the injection d. the preferred site of injection is the lateral abdominal fatty tissue