,
, NURSING IMPLICATIONS
Assessment
• Assess for signs of bleeding and hemorrhage (bleed-
ing gums; nosebleed; unusual bruising; tarry, black Clearly defined
stools; hematuria; fall in hematocrit or BP; guaiac- nursing responsibilities
positive
1286 stools,
f i urine, or nasogastric aspirate).
warfarin
and priorities
• Assess for evidence of additional or increased PO: Administer medication at same time each day.
• P
thrombosis. Symptoms depend on area of involve- Medication requires 3– 5 days to reach effective lev-
ment. els; usually begun while patient is still on heparin.
• Lab Test Considerations: Monitor PT, INR and • Do not interchange brands; potencies may not be
other clotting factors frequently during therapy; equivalent. In-depth guidance
monitor more frequently in patients with renal im-
pairment. Therapeutic PT ranges 1.3– 1.5 times Patient/Family Teaching for patient and
• Instruct patient to take medication as directed. Take
greater than control; however, the INR, a standard-
ized system that provides a common basis for com- missed doses as soon as remembered that day; do family education
municating and interpreting PT results, is usually re- not double doses. Inform health care professional of
ferenced. Normal INR (not on anticoagulants) is missed doses at time of checkup or lab tests. Inform
0.8– 1.2. An INR of 2.5– 3.5 is recommended for patients that anticoagulant effect may persist for 2– 5
patients at very high risk of embolization (for exam- days following discontinuation. Advise patient to
ple, patients with mitral valve replacement and ven- read Medication Guide before starting therapy and
tricular hypertrophy). Lower levels are acceptable with each Rx refill in case of changes.
when risk is lower. Heparin may affect the PT/INR; • Review foods high in vitamin K (see Appendix K).
draw blood for PT/INR in patients receiving both Patient should have consistent limited intake of these
heparin and warfarin at least 5 hr after the IV bolus foods, as vitamin K is the antidote for warfarin, and
dose, 4 hr after cessation of IV infusion, or 24 hr af- alternating intake of these foods will cause PT levels
ter subcut heparin injection. Asian patients and to fluctuate. Advise patient to avoid cranberry juice
those who carry the CYP2C9*2 allele and/or the or products during therapy.
CYP2C9*3 allele, or those with VKORC1 AA genotype • Caution patient to avoid IM injections and activities
may require more frequent monitoring and lower leading to injury. Instruct patient to use a soft tooth-
doses. brush, not to floss, and to shave with an electric ra-
• Geri: Patients over 60 yr exhibit greater than ex- zor during warfarin therapy. Advise patient that veni-
pected PT/INR response. Monitor for side effects at punctures and injection sites require application of
lower therapeutic ranges. pressure to prevent bleeding or hematoma forma-
• Pedi: Achieving and maintaining therapeutic PT/INR tion.
ranges may be more difficult in pediatric patients. • Advise patient to report any symptoms of unusual
Assess PT/INR levels more frequently. bleeding or bruising (bleeding gums; nosebleed;
• Monitor hepatic function and CBC before and peri- black, tarry stools; hematuria; excessive menstrual
odically throughout therapy. flow) and pain, color, or temperature change to any
• Monitor stool and urine for occult blood before and area of your body to health care professional imme-
periodically during therapy. diately. Patients with a deficiency in protein C and/
• Toxicity and Overdose: Withholding 1 or more or S mediated anticoagulant response may be at
doses of warfarin is usually sufficient if INR is exces- greater risk for tissue necrosis.
sively elevated or if minor bleeding occurs. If over- • Instruct patient not to drink alcohol or take other
dose occurs or anticoagulation needs to be immedi- Rx, OTC, or herbal products, especially those con-
ately reversed, the antidote is vitamin K taining aspirin or NSAIDs, or to start or stop any new
(phytonadione, Aquamephyton). Administration of medications during warfarin therapy without advice
whole blood or plasma also may be required in se- of health care professional.
vere bleeding because of the delayed onset of vita- • Advise patient to notify health care professional if
min K. pregnancy is planned or suspected or if breast feed- More patient safety
ing.
Implementation • Instruct patient to carry identification describing information than
• High Alert: Do not confuse Coumadin (warfarin) medication regimen at all times and to inform all
with Avandia (rosiglitazone) or Cardura (doxazo- health care personnel caring for patient on anticoag-
any other drug guide
sin). Do not confuse Jantoven (warfarin) with Janu- ulant therapy before lab tests, treatment, or surgery.
met (sitagliptin/metformin) or Januvia (sitagliptin). • Emphasize the importance of frequent lab tests to
• Because of the large number of medications capable monitor coagulation factors.
of significantly altering warfarin’s effects, careful
monitoring is recommended when new agents are Evaluation/Desired Outcomes
started or other agents are discontinued. Interactive • Prolonged PT (1.3– 2.0 times the control; may vary
potential should be evaluated for all new medica- with indication) or INR of 2– 4.5 without signs of
tions (Rx, OTC, and herbal products). hemorrhage.
Canadian drug name. Genetic implication. Strikethrough Discontinued.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
Find enhanced Canadian content
throughout—in the monographs,
appendices, and index.
Uncorrected page proofs. Contents may vary upon publication.
© F.A. DavisA Publishing
L Gr a wa n y
, © F.A. Davis Publishing
, NURSING IMPLICATIONS
Assessment
• Assess for signs of bleeding and hemorrhage (bleed-
ing gums; nosebleed; unusual bruising; tarry, black Clearly defined
stools; hematuria; fall in hematocrit or BP; guaiac- nursing responsibilities
positive
1286 stools,
f i urine, or nasogastric aspirate).
warfarin
and priorities
• Assess for evidence of additional or increased PO: Administer medication at same time each day.
• P
thrombosis. Symptoms depend on area of involve- Medication requires 3– 5 days to reach effective lev-
ment. els; usually begun while patient is still on heparin.
• Lab Test Considerations: Monitor PT, INR and • Do not interchange brands; potencies may not be
other clotting factors frequently during therapy; equivalent. In-depth guidance
monitor more frequently in patients with renal im-
pairment. Therapeutic PT ranges 1.3– 1.5 times Patient/Family Teaching for patient and
• Instruct patient to take medication as directed. Take
greater than control; however, the INR, a standard-
ized system that provides a common basis for com- missed doses as soon as remembered that day; do family education
municating and interpreting PT results, is usually re- not double doses. Inform health care professional of
ferenced. Normal INR (not on anticoagulants) is missed doses at time of checkup or lab tests. Inform
0.8– 1.2. An INR of 2.5– 3.5 is recommended for patients that anticoagulant effect may persist for 2– 5
patients at very high risk of embolization (for exam- days following discontinuation. Advise patient to
ple, patients with mitral valve replacement and ven- read Medication Guide before starting therapy and
tricular hypertrophy). Lower levels are acceptable with each Rx refill in case of changes.
when risk is lower. Heparin may affect the PT/INR; • Review foods high in vitamin K (see Appendix K).
draw blood for PT/INR in patients receiving both Patient should have consistent limited intake of these
heparin and warfarin at least 5 hr after the IV bolus foods, as vitamin K is the antidote for warfarin, and
dose, 4 hr after cessation of IV infusion, or 24 hr af- alternating intake of these foods will cause PT levels
ter subcut heparin injection. Asian patients and to fluctuate. Advise patient to avoid cranberry juice
those who carry the CYP2C9*2 allele and/or the or products during therapy.
CYP2C9*3 allele, or those with VKORC1 AA genotype • Caution patient to avoid IM injections and activities
may require more frequent monitoring and lower leading to injury. Instruct patient to use a soft tooth-
doses. brush, not to floss, and to shave with an electric ra-
• Geri: Patients over 60 yr exhibit greater than ex- zor during warfarin therapy. Advise patient that veni-
pected PT/INR response. Monitor for side effects at punctures and injection sites require application of
lower therapeutic ranges. pressure to prevent bleeding or hematoma forma-
• Pedi: Achieving and maintaining therapeutic PT/INR tion.
ranges may be more difficult in pediatric patients. • Advise patient to report any symptoms of unusual
Assess PT/INR levels more frequently. bleeding or bruising (bleeding gums; nosebleed;
• Monitor hepatic function and CBC before and peri- black, tarry stools; hematuria; excessive menstrual
odically throughout therapy. flow) and pain, color, or temperature change to any
• Monitor stool and urine for occult blood before and area of your body to health care professional imme-
periodically during therapy. diately. Patients with a deficiency in protein C and/
• Toxicity and Overdose: Withholding 1 or more or S mediated anticoagulant response may be at
doses of warfarin is usually sufficient if INR is exces- greater risk for tissue necrosis.
sively elevated or if minor bleeding occurs. If over- • Instruct patient not to drink alcohol or take other
dose occurs or anticoagulation needs to be immedi- Rx, OTC, or herbal products, especially those con-
ately reversed, the antidote is vitamin K taining aspirin or NSAIDs, or to start or stop any new
(phytonadione, Aquamephyton). Administration of medications during warfarin therapy without advice
whole blood or plasma also may be required in se- of health care professional.
vere bleeding because of the delayed onset of vita- • Advise patient to notify health care professional if
min K. pregnancy is planned or suspected or if breast feed- More patient safety
ing.
Implementation • Instruct patient to carry identification describing information than
• High Alert: Do not confuse Coumadin (warfarin) medication regimen at all times and to inform all
with Avandia (rosiglitazone) or Cardura (doxazo- health care personnel caring for patient on anticoag-
any other drug guide
sin). Do not confuse Jantoven (warfarin) with Janu- ulant therapy before lab tests, treatment, or surgery.
met (sitagliptin/metformin) or Januvia (sitagliptin). • Emphasize the importance of frequent lab tests to
• Because of the large number of medications capable monitor coagulation factors.
of significantly altering warfarin’s effects, careful
monitoring is recommended when new agents are Evaluation/Desired Outcomes
started or other agents are discontinued. Interactive • Prolonged PT (1.3– 2.0 times the control; may vary
potential should be evaluated for all new medica- with indication) or INR of 2– 4.5 without signs of
tions (Rx, OTC, and herbal products). hemorrhage.
Canadian drug name. Genetic implication. Strikethrough Discontinued.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
Find enhanced Canadian content
throughout—in the monographs,
appendices, and index.
Uncorrected page proofs. Contents may vary upon publication.
© F.A. DavisA Publishing
L Gr a wa n y
, © F.A. Davis Publishing
