Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation

Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Case Study 7 Atrial Fibrillation and Oral Anticoagulation Scenario You are the nurse working in an anticoagulation clinic. One of your patients is K.N., who has a long- standing history of an irregular heartbeat, known as atrial fibrillation or A-fib, for which he takes the oral anticoagulant warfarin (Coumadin). Recently K.N. had his mitral heart valve replaced with a mechanical valve. 1. How does atrial fibrillation differ from a normal heart rhythm? Atrial fibrillation is characterized by a total disorganization of atrial electrical activity due to multiple ectopic foci, resulting in the loss of effective atrial contraction. (Elsevier) In other words, A-fib occurs due to irritable sites in the atria. These fire at a rate of 400-660 times per min. These rapid impulses cause the muscles of the atria to quiver aka fibrillate. This results in ineffectual atrial contraction, decreased stroke volume, and ultimately a decrease in cardiac output, and a loss of atrial kick. (ECG’s Made Easy 3rd edition, MosbyJems) This differs from a normal heart rhythm because a normal aka sinus rhythm is 60-100bpm and has a regular rhythm. This means that normal electrical activity starts in the SA node and then heads down the normal conduction path through the atria, AV junction, bundle branches, and ventricles. . (ECG’s Made Easy 3rd edition, MosbyJems) 2. What is the purpose of the warfarin (Coumadin) in K.N.'s case K.N. Health history: chronic A-fib, coumadin therapy, mitral heart valve replaced with mechanical valve. In the case of K.N., the purpose of coumadin is needed after rate control drugs such as calcium channel blockers, b blockers, dronedarone, and digoxin fail. Coumadin is also used if cardioversion does not convert atrial fibrillation to normal sinus rhythm. For long term anticoagulation therapy warfarin is the drug of choice. This in turn means monitoring of INR to insure therapeutic levels are being maintained. Additionally, in mechanical heart valve replacement coumadin is the drug of choice to percent blood clots. (Elsevier p. 766) CASE STUDY PROGRESS K.N. calls your anticoagulation clinic to report a nosebleed that is hard to stop. You ask him to come into the office to check his coagulation levels. The laboratory technician draws a PT/INR test. This study source was downloaded by from CourseH on :18:49 GMT -05:00 This study resource was shared via CourseH3. What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of the INR? Prothrombin Time- 11 to 14 seconds: Plasma 1ml collected in a blue top tube. Prothrombin time is a coagulation test to measure the time it takes for a firm fibrin clot to form after tissue thromboplastin and calcium are added to the sample. It evaluates the extrinsic pathway of the coagulation sequence to patients rcving PO warfarin OR coumarin type anticoagulants. Prothrombin is a vitamin k dependent protein produced by the liver. It is measured as time in seconds. INR-0.9-1.2: for patients with mechanical heart valves and/or rcvng treatment for recurrent systemic embolism. International normalized ratio measures the amount of time it takes for blood to clot. The expected levels for K.N. would be 2.0-3.0 for patients receiving treatment for venous thrombosis, pulmonary embolism, and valvular heart disease. (Davis’s comprehensive handbook of laboratory and diagnostic tests second edition) 3. When you get the results, his international normalized ratio (INR) is critical at 7.2. What is the danger of this INR level? This means that the pt blood is dangerously thin which increases the risk for internal bleeding. S/S to look out for in addition to critical labs are prolonged bleeding from cuts or gums, hematoma at puncture site, hemorrhage, blood in the stool, persistent epistaxis, and shock. (Davis’s comprehensive handbook of laboratory and diagnostic tests second edition) CASE STUDY PROGRESS The health care provider does a brief focused history and physical examination, orders additional lab- oratory tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped. The provider discovers that K.N. recently started to take daily doses of an over-the-counter pro- ton pump inhibitor (PPI), omeprazole (Prilosec OTC), for heartburn. 5.What happened when K.N. began taking the PPI? PPI have been suggested to increase the effect of warfarin. Therefore, it is likely that when pt began taking the PPI in addition to Coumadin, the effects were increased causing epistaxis. 6. What should K.N. have done to prevent this problem? K.N. could have prevented this problem by consulting his PCP prior to taking an OTC medication. He could have also been his own advocate by researching contraindications wihle taking coumadin. This study source was downloaded by from CourseH on :18:49 GMT -05:00 This study resource was shared via CourseH7.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? The administration of Vitamin K will help because it assists in blood clotting. The body needs vitamin K to produce prothrombin. As mentioned earlier, prothrombin is a protein and clotting factor. 8.You want to make certain K.N. knows what “hold the next dose” means. What should you tell him? I would ask K.N. to repeat back to me what he thinks “hold the next dose” means. 9.K.N. asks you why his PT/INR has to be checked so soon. How will you respond? I would respond by telling him that his PT inr levels have to be monitored very closely. It is important to know that the Vitamin K has been effective in returning his levels to a therapeutic range. CASE STUDY PROGRESS 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. 10. Why should the INR be checked again so soon instead of the usual monthly follow-up? When there is a critical finding follow up should not be postponed until a month from discovery. Closely monitoring the patient will ensure that any status changes are caught in a safe time frame. 11. K.N. grumbles about all of the laboratory 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. Black, tarry stool b. Stool that is pale in color c. New onset of dizziness d. Insomnia e. New joint pain or swelling- although uncommon, haemarthrosis can be a complication of anticoagulation therapy.( f. Unexplained abdominal pain Answer: A,C,E,F. Rationale is the potential for internal bleeding, specifically in head or abdomen. This study source was downloaded by from CourseH on :18:49 GMT -05:00 This study resource was shared via CourseH12. Identify two other patient education needs that you need to stress at this time. a. Adherence to doctors orders with medication administration to maintain therapeutic levels, including diet and the intake of foods with vitamin k. b. Being cautious with shaving, bumping into things, falls. 13. 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? I will pass this information along to the PCP. I would also obtain consent to have the surgeon and PCP connect in order to possible agree on discontinuing the coumadin 5-7 days prior to surgery. It is important for the surgeon to be aware of a full list of medications, especially with blood thinners and to ensure that the pt has disclosed pertinent health history such as atrial fibrillation. A cardiac clearance would likely be necessary due to his history of valve replacement. CASE STUDY PROGRESS You know that sometimes the only needed action is to stop the warfarin (Coumadin) several days before the surgery. Other times, the provider initiates“bridging therapy,”or stops the warfarin and provides anti- coagulation protection by initiating low-molecular-weight heparin. After reviewing all of his anticoagula- tion information, the provider decides that K.N. will need to stop the warfarin (Coumadin) 1 week before the surgery and in its place be started on enoxaparin (Lovenox) therapy. 14. Compare the duration of action of warfarin (Coumadin) and enoxaparin (Lovenox) and explain the reason the provider switched to enoxaparin at this time. Instead of the pt being off of his warfarin for 5-7 days, he will only need to be off of lovenox for a period of 12-24 hours prior to surgery. CASE STUDY PROGRESS K.N. is in the office and ready for his first enoxaparin (Lovenox) injection. 15. Which nursing interventions are appropriate when administering enoxaparin? Select all that apply. a. Monitor activated partial thromboplastin time (aPTT) levels. b. Administer via intramuscular (IM) injection into the deltoid muscle. c. The preferred site of injection is the lateral abdominal fatty tissue. d. Massage the area after the injection has been given. e. Hold extra pressure over the site after the injection Answer: A, C This study source was downloaded by from CourseH on :18:49 GMT -05:00 This study resource was shared via CourseHWhen under anticoagulant therapy it is always crucial to monitor clotting levels. The activated partial thromboplastin time is indicated to evaluate response to anticoagulant therapy with heparin or coumarin. It also assists in identifying individuals who may be prone to bleeding such as having a surgical procedure. Never hold pressure over an injection site of a blood thinner as it can cause bruising or hematoma. CASE STUDY PROGRESS K.N. undergoes knee surgery without complications. Just before his discharge, his physician reviews the instructions and gives him a new prescription for warfarin (Coumadin). 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.” 16. How do you expect the physician to respond? Xarelto is not recommended for patients with prosthetic heart valves. ( I found this in the 2020 Nurses drug book and am not sure if the patient qualifies as having a prosthetic heart valve?) Otherwise, I would expect the provider to reply by stating that although changing the medication may have benefits, there will still need to be routine blood work done in order to maintain stable therapeutic levels. Anticoagulants are serious medications and should be monitored closely. CASE STUDY OUTCOME K.N. is discharged to a rehabilitation facility where he makes a quick recovery from the knee replacement surgery. He does not experience any thrombotic events or bleeding episodes during his recovery. This study source was downloaded by from CourseH on :18:49 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()