Warfarin Safety for Nursing Homes - Welcome to … Safety for Nursing Homes ... May be on a nursing...
Transcript of Warfarin Safety for Nursing Homes - Welcome to … Safety for Nursing Homes ... May be on a nursing...
Warfarin Safety for Nursing HomesNursing Homes
Dianne Roux-LirangeJanuary 2010
OverviewA Background – Hx of warfarinB How warfarin worksB How warfarin worksC Indications for useD Side effects - BleedingD Side effects BleedingE Bleeding is minimized with monitoringF Dose adjustment and managementF Dose adjustment and managementG When INR is OK, hemorrhage may occurH MedPass charting and F/UH MedPass, charting, and F/UI Wrap-Up
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A The History of Warfarin
Farmers’ Alarm1920s: Cattle were hemorrhaging to death
Found to be due to a contaminant in their dietS il d t l i th i f d hi h t i dSpoiled sweet clover was in their feed which contained a chemical substanceIt interfered with the coagulation process
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The History of Warfarin
Discovery of warfarin1940s: at the University of Wisconsin
Synthesized a chemical, dicumarol, A d d th t it id ti l t thAnd proved that it was identical to thenaturally occurring agent in sweet cloverThey patent the compound WARFarin, y p p ,a play on the name of their office,Wisconsin Alumni Research Foundation,
It is marketed as a rat pesticide/poison
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The History of Warfarin
FDA patent1954: Endo labs take out the first patent for human use
It is filed as Coumadin the brand name of warfarinIt is filed as Coumadin, the brand name of warfarinIt was found to be effective and relatively safe for preventing thrombosis and embolism (abnormal formation and migration of blood clots) in manyformation and migration of blood clots) in many disorders
Warfarin, the generic version of Coumadin, was filed in 1995
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B How Warfarin Works
Warfarin is an anticoagulantSubstance that “thins” the blood
Clinically used to reduce the body’s ability to form bl d l t t t bl d l tblood clots – to prevent blood clotsSeems to “thin” the blood so that cuts “won’t stop bleeding”bleedingIt disrupts the coagulation processg p
Other namesCoumadin®, Jantoven®
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How Warfarin Works
(1a)Understanding coagulation(1a)Understanding coagulation
Coagulation converts fluid bloodinto a fibrin clot at the site of injury
Normally, clot formation does not occur within a healthy,
intact blood vessel
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How Warfarin Works(1b)Understanding coagulation
Coagulation process is activated whenCoagu at o p ocess s act ated einjury/damage into the wall of a blood vessel (cells of the vascular endothelium)A b t l k tA substance leaks out
Then the vitamin K process Kicks inVitamin K is a chemical that is one of our vitamins (vitaminsVitamin K is a chemical that is one of our vitamins (vitamins are vital/essential to life/health)Vitamin K is absorbed from the digestive tract and travels to the liver to workthe liver to workK Kauses “KOAGULATION”In the liver, Vitamin K produces a clotting factorg
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How Warfarin Works(1c)Understanding
coagulationThen vitamin K process Kicks in
In the liver, Vitamin K produces PROTHROMBINVitamin K is at the top of one of the coagulation pathwaysProthrombin circulates in the blood systemA damaged cells triggers it to plug holes in the walls
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How Warfarin Works(2a)Warfarin stops clots by stopping the action stopping the action of vitamin K STOPSSTOPS
Vitamin K makes prothrombinWhen triggered, prothrombin makes clotting factorsThis leads to making fibrinFibrin with platelets form theFibrin with platelets form the clot
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How Warfarin Works
(2b)Warfarin stops clots by stopping vitamin Kvitamin K
It is classified as an anti coagulantIt is an anticoagulant known as a vitamin KIt is an anticoagulant known as a vitamin K antagonist (VKA)
It turns on the blood flow by disrupting the vitaminIt turns on the blood flow by disrupting the vitamin K pathway (one path in the coagulation process)
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How Warfarin WorksWarfarin has a delayed effect when first
startedstartedIt takes 2-3 days – compared to other drugs, this is a very long onset of action BECAUSEy gClotting factors, like Prothrombin, that have already been made by the body are still present and still making fibrin clotsNeed overlap therapy with an immediate acting
ti l t if id i d i danticoagulant if rapid response is desiredHeparin, Lovenox (enoxaparin), Arixtra (fondaparinux),
Fragmin (dalteparin)g ( p )
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C Indication for warfarin therapyIt is the most commonly prescribed
anticoagulantAbout 31 Million prescriptions dispensed in 2004
But it is a risky medication andMostly responsible for serious & life-
threatening adverse reactionsthreatening adverse reactionsNarrow Therapeutic Window Fine line between being helpful and being harmfulbetween being helpful and being harmful
Among the top 5 drugs contributing to ER visitsAmong the top 2 drugs causing hospitalizationg p g g p
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Indication for warfarin therapypyUsed for abnormal vascular conditions in
which there are inappropriate clot pp pformations in an uninjured blood vessel
Clots such asThrombus – is a blood clot. Clotting is normal with blood vessel injury but pathological otherwise.Embolism – occurs when part of a thrombus b k d t l th h thbreaks away and travels through the bloodstream. It can block the blood supply to organs.organs.
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Indication for warfarin therapyConditions
Prevention of embolism in patients:Prevention of embolism in patients:With artificial heart valvesWith atrial fibrillation to prevent strokeWith atrial fibrillation to prevent strokes/p heart attack
Prevention & Treatment of venousPrevention & Treatment of venous thromboembolism (VTE)
Deep vein thrombosis (DVT)● Prevent DVT in patients with prolonged bed rest
Pulmonary embolism (PE)
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Atrial Fibrillation
Atria of the heart are not contracting properly
Pooling of blood in the heartIncreased risk of thrombus formationo at o● May lead to stroke● Warfarin reduces risk of
strokestroke
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Venous Thromboembolism VTE
Deep vein thrombosis DVT
Thrombus develops in the deep veins
Usually in the legsSymptoms
Swelling, warmth, redness, pain, engorged superficial veins● Not all symptoms are always
present
May break away and cause PE
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Venous Thromboembolism VTEPulmonary embolism PE
Part of a clot formed in th b d ( ll i ththe body (usually in the legs) breaks off & travels to the main artery of the lungsSymptoms
Chest pain difficultyChest pain, difficulty breathing, cyanosis, rapid breathing and heart rateheart rateSome people may cough up blood (but not everyone!)
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everyone!)
Who is at Risk for VTEElder Age
Risk doubles for every d d ft th f
Vascular InjuryOrthopedic surgery
decade after the age of 50
History of VTE
Knee/hip replacementTrauma
Strongest known risk factor for DVT/PE
Limited mobility
Pelvis, hip, leg fracture
Hypercoagulable StatesLimited mobility
Prolonged bed restMajor medical illness
StatesCancer
Drugs(CHF, MI)ParalysisObesity
gBirth control pillsEstrogen replacementObesity
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D Side Effects of WarfarinBleeding!!!
Most common side effect ofMost common side effect of warfarin use
Minor bleeding occurs in 14% to g36% of patientsMajor bleeding (serious, life-th t i f t lthreatening, or fatal hemorrhage) occurs in 5% to 7.9% of patients
● Hylek EM, Seminars in Vascular Medicine 2003 and Hylek EM, Circulation 2007
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BleedingMinor bleeding is common among warfarin userseven when patients are well managed on warfarin
Small bleeding from mucous membranes while brushing teeth (friable gums)
f th ( i t i )or from the nose (epistaxis)Easy bruising – may begin with ecchymoses (purple patches)ecchymoses (purple patches)Bleeding from a small cut
May be on a nursing care plan May be on a nursing care plan for easy bruising and/or bleeding
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BleedingMinor bleeding is common among usersBut Minor becomes serious bleeding when
Gums won’t stop bleedingp gA bruise that grows for no reasonA cut that is still bleeding after 10 minutesg
Requires a nursing note in chart.
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Signs & symptoms of major bleedingMay mean internal hemorrhage, such as, gastrointestinal or cerebral,Follow procedure to place call to doctorFollow procedure to place call to doctorNursing Assessment:^Vomiting blood or gastric contents that
Patient Complaint:Vomiting blood or gastric contents that
looks like coffee grounds (hematemesis)
^Stools that are bloody or are dark and
^Severe abdominal pain^Persistent headaches
^Stools that are bloody or are dark and tar-like (hematochezia)
^Urine that is red or unusually dark ^Confusion or decreased
alertness(hematuria)
^Coughing up phlegm that is bloody (hemoptysis)
^Dizziness or weakness
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(1) Your “Warfarin Watch” ListBleeding may be more serious
for patientsfor patients(1a) With certain conditions(1b) Who fall(1b) Who fall
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(1a) Your “Warfarin Watch” ListWatch for bleeding in certain patients
Bleeding risk is increased with patients having the following conditionshaving the following conditions
Patients also receiving concomitant antiplatelet drugs (clopidogrel (Plavix) and/or aspirin)antiplatelet drugs (clopidogrel (Plavix) and/or aspirin)Patients older than 65 yrsPatients with prior stroke renal impairment or anemiaPatients with prior stroke, renal impairment or anemia
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(1b) Your “Warfarin Watch” ListPatients who have a history of falls and/or are not
steady on their feet Aft f ll hit th h d Th I id t R t After a fall or hit on the head, The Incident Report
should have these notesYES � or NO �YES � or NO �
1-Visible bleeding? If so, severity?2-Symptoms of internal bleeding? y p g3- Symptoms of IntraCranial Hemorrhage?
If so, do first neuro-checkPatient is on warfarinWith this information, per policy, place call to doctor
● Continue FOLLOW-UP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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(1b) Your “Warfarin Watch” List. . . .The Incident Report should have these notes
Follow-upContinue neuro-check, if started
YES � or NO �Symptoms of bleeding that was not present before?not present before?
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E Bleeding is minimized with monitoringWarfarin therapy is proven to be effective
and safe WITH MONITORINGMonitoring involves scheduled blood tests
and reviewing results so that warfarin may be adjusted accordingly
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Bleeding is minimized with monitoring(1)Scheduled blood tests
Two blood test are available- both involveTwo blood test are available both involve measuring prothrombinBecause
When a blood vessel is damaged,
Vit i K ki k iVitamin K process kicks in,
Circulating prothrombin is activated
Leading to clot formation
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Bleeding is minimized with monitoring
(2)Scheduled blood tests(2)Scheduled blood testsProthrombin time (PT) assay
Measures the time it takesMeasures the time it takesfor prothrombin to form a clot
International Normalized Ratio (INR)International Normalized Ratio (INR)INR value is the patient’s prothrombin time as a ratio using international reference standardsratio using international reference standards
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Bleeding is minimized with monitoringFor patients on warfarin, tests results are:
prothrombin time (PT) is longerp ( ) gINR value is greater
than normalthan normal
Normal values (for patients not on warfarin):PT is anywhere between 11 0 and 13 0 seconds andPT is anywhere between 11.0 and 13.0 seconds, and value varies from lab to labINR is 1.0 (one)
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(1) INR schedules/guidesDosing is guided by two different INR
guides based ong(1a) Initiation dosing – for patients beginning VKA therapy(1b) Maintenance dosing - for chronic VKA therapy
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(1a) INR schedules/guidesWhen warfarin is started, dosingis guided by INR (per doctor’s orders)is guided by INR (per doctor s orders)
It takes 2-3 days for warfarin to take effectTo cover this delay: heparin-anticoagulants are coadministered for 4-5 days to provide coverageThis is called the “loading phase”
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(1a) INR schedules/guidesWhen warfarin is started, dosingis guided by INR (per doctor’s orders)is guided by INR (per doctor s orders)
Prescribers use a dose algorithm (a guide) to prescribe the(a guide) to prescribe the appropriate dose
Prescribers orderPrescribers order More INR tests in the first several weeksAnd then weekly until the INR is stableAnd then weekly until the INR is stableThen monthly – this is the usual scheduling of testing for patients on chronic warfarin therapy
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(1b) INR schedules/guidesFor chronic warfarin therapy, dosing is guided by INR (per doctor’s orders)dosing is guided by INR (per doctor’s orders)
The target INR for most conditions is 2.5 with an acceptable range of 2 0 to 3 0acceptable range of 2.0 to 3.0. For some patients the INR goal will be 3.0 with a range of 2.5 to 3.5 (for those with artificial heart g (valves, recurrent clots, etc.)
When INR response is stable, frequency of testing may be reduced to once every 4 weeks
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(1b) INR schedules/guidesFor chronic warfarin therapy
2.0 -------------------------3.0
INRINR
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Bleeding is minimized with monitoringWhen surgery or a procedure is scheduled for a patient on warfarinp
Per doctor’s orders:Warfarin may stopped some time before and y ppresumed sometime after
OR“Bridge therapy” may be ordered (if the risk of clotting is high) which means another anticoagulant is used to bridge the time patient is off warfarin during the peri-operative period
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F Dose Adjustment and ManagementFrequent dose changes are common, per
doctor’s orders, for these reasons:Each person responds differently to warfarin (age, liver health, CHF, fever)W f i i di t bl it i t tWarfarin is unpredictable: it interacts with other medications and foods
And the INR range is difficult to achieveAnd the INR range is difficult to achieveCompared to other drugs, the therapeutic window/range is very narrowg y
To counteract this, the doctor individualizes dosing based on INR level
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Dose Adjustment and ManagementFor chronic warfarin therapy
2.0 -------------------------3.0
INR
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Dose Adjustment and Management
(1a)Interaction with other medicationsDrugs that may prolong PT/increase INR:
ANTIBIOTICS, antifungals, H2 blockers, PP inhibitors, antidepressants, CaCblockers, antiarrythmics (amiodarone), lipid lower agents (Zocor), anticonvulsants (phenytoin Dilantin)(Zocor), anticonvulsants (phenytoin Dilantin)
Drugs that may shorten PT/decrease INR:Barbiturates, anticonvulsants(carbamazepineBarbiturates, anticonvulsants(carbamazepineTegretol)
● Continue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Dose Adjustment and Management
(1b)Interaction with other medications and supplementsand supplements
Over-the-Counter Pain RelieversSalicylates Aspirin NSAIDs: ibuprofen (Motrin Advil)Salicylates Aspirin, NSAIDs: ibuprofen (Motrin, Advil), naproxen (Aleve)
Increase bleeding risk
Herbal SupplementsGinseng, Gingko, Garlic, St. John’s Wort, & many others!others!
Some increase bleeding risk, others increase clot risk
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Dose Adjustment and Management(1c) Lists of
other di timedications
Drug interaction lists can be found:
1- from your pharmacy vendor1 from your pharmacy vendor2- in patient package insert
for Coumadin3- on the internet – see
example ofexample of www.drugs.com site for search box and lists of common drugs and 186 major interactionsmajor interactions
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Dose Adjustment and Management
(1d) It is often impossible to predict how a specific medication will affect a a specific medication will affect a patient’s INR
Always obtain a stat INR within 3-7 daysAlways obtain a stat INR within 3-7 days
When starting an antibioticWhen any change (start, stop, dosing) of any medication
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Dose Adjustment and Management(2a) Vitamin K and Interacting Foods
Sources of vitamin K is through digestionSources of vitamin K is through digestionFrom the diet and bacterial products in the large intestinePeople on warfarin can eat foods high in Vitamin K, as long as they do so consistently
Concern is about major changes in Vitamin K intakej g
Nurses on maternity units know: vitamin K shots are given to newborns to prevent bleeding – they are vitamin K deficient because the intestines haveare vitamin K deficient because the intestines have not yet been colonized with bacteria
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(2b) Vitamin K Content of Foods (see list)
Very High High Medium Low
Brussel sprouts
Chi k
Basil
B li
Green Apple
A
Fruits
A dChick peas
Collard greens
Coriander
Endive
Broccoli
Chive
Coleslaw
Cucumber (w/
Asparagus
Cabbage
Cauliflower
Mayonnaise
Avocado
Beans
Breads/grains
Carrots
Kale
Lettuce, Red Leaf
Parsley
(peel)
Canola oil
Green onion/Scallion
y
Pistachios
Squash, summer
Celery
Coffee
Corn
Spinach
Swiss Chard
Tea, Green
Watercress
Soybean oil Cucumber (w/o peel)
Dairy products
Eggs
Lettuce, IceburgWatercress Lettuce, Iceburg
Meats, fish, poultry
Pasta
Peanuts
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Dose Adjustment and Management
.
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Dose Adjustment and Management(3a)Expect dose adjustment whenINR is nontherapeuticINR is nontherapeuticWhen INR is slightly out of therapeutic range,
doctor manages the dosing byNo dose change but more frequent INR testing – expecting the INR to return to therapeutic levelsORORAdjusting the dose by 5%, 10%, 15% or 20% based on the weekly dose of warfarin
Expect an order for INR test after a dose change – may see INR effect of new warfarin dosage in 2-3 days y
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Dose Adjustment and Management(3b)Expect dose adjustment when<<INR value is out-of-target range>> <<INR value is out of target range>> and no bleeding (asymptomatic) or minor bleeding bleeding If INR increased but not > 5.0, dose may be reduced
By lowering weekly dose (* by certain %) or omitting dose(s)By lowering weekly dose ( by certain %) or omitting dose(s)i.e., if patient’s INR is 3.6, doctor will decrease dose by 15% hoping to hit an INR of 2.6 (one whole change in INR value)
If INR decreased doctor may increase doseIf INR decreased, doctor may increase doseBy increasing weekly dose (* by certain %)
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Dose Adjustment and Management(3c) Expect other med orders whenINR value is out-of-target range >>5.0 and INR value is out of target range >>5.0 and
<<10.0andandnon-life threatening bleeding
Med orders may be:Med orders may be:Stop warfarinGive antidote to reverse VKA over-coagulation● vitamin K (phytonadione Mephyton®) PO
● (note if there’s a repeat dose in 6 -12 hours) – recall vitamin K works in the coagulation process so expect that effects are not immediate (it works slowly)
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Dose Adjustment and ManagementSummary – MedexFor warfarin managementg-orders for adjustmentsIs not completed
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Dose Adjustment and ManagementSummary – MedexFor warfarin managementg-AdjustmentsPer doctor’s orders
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G When INR is OK (in the therapeutic range) hemorrhage may occurg ) g yConsider possibility of hemorrhage with a
patient whose complaints don’t patient whose complaints don t indicate an obvious diagnosis:
Anticoagulated patients,regardless of INR, are at g p grisk of major bleeding events Use your clinical skills and observe your patients for these s&s:M t i i th h t bd j i tMay present as pain in the chest, abdomen, joints, or muscle, paralysis, headache, dizziness, shortness of breath, difficulty breathing or swallowing, unexplained swelling, or weakness.Finally hypotension leading to unexplained shock
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When INR is OK, hemorrhage may occur
Laboratory tests for signs of blood lossFor anemia: complete blood count, hemoglobin and hematocrit values, S h i tSerum chemistry,For urinary tract bleeding: urinanalysis
Other meas res/testsOther measures/testsVital signs showing low blood pressure and fast heart rateheart rate For GI bleeding/hematochezia: fecal occult blood test (FOBT)
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When INR is OK, hemorrhage may occur If life-threatening bleeding
THIS IS AN EMERGENCY Follow protocol for calling doctor and transferring patient to ED
ED will institute life-saving treatments to reverse anticoagulationF h f l (FFP) d it i KFresh frozen plasma (FFP) and vitamin K (phytonadione injectable emulsion) are most frequently administeredq yCoagulation factor concentrates (i.e., prothrombin complex concentrate (PCC)) may be administered
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H MedPass, charting, and F/URoutine activities - may have standard
policy/procedures for the following)
M d P ( b / h i d i )Med Pass (may be new/changes in dosing)Check-off lab receipt for incoming INR reportsT k ff d hl i d O dTake off new orders or monthly printed OrdersFollow up phlebotomy / POC finger prick schedule
Other activitiesLab calls with an alert valueFollow up patient care (abnormal BPs or complaints)
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MedPass, charting, and F/UOn Med Run, expect - there is no
“typical” dose of warfarinEach person responds differently to
warfarin
D i di id li dDoses are individualizedFrequent dose changes are commonHigh or low INR levels are not reconciled by changing the daily dose of warfarin, but rather by altering the total weekly doserather by altering the total weekly dose
Results in crazy-wacky dosing schedules
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MedPass, charting, and F/UDosing is reconciled with INR levels by
altering the total weekly doseThe new orders may look unusual – see this example
Mr. Smith takes 5 mg daily. His goal INR is 2-3, but today his INR is 3 6 (too high!)but today his INR is 3.6 (too high!)His warfarin dose needs to be decreased
Calculate his total weekly dose (= 35 mg/week)Decrease the total weekly dose by 15% (15% equates to one whole INR change.)● 15% of 35 is 5 mg. Total weekly dose is 30 mg (=35 – 5 mg)
New orders are – 5 mg daily, except on Tuesday & Thursday take 2.5 mgThursday take 2.5 mg
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MedPass, charting, and F/UThe Dosing Game
Mrs Jones is on 2 mg/day
1 mg pink
2 mg lavender Mrs. Jones is on 2 mg/day
How many ways can we make 2 mg dose of warfarin?
2-1/2 mg green
3 mg tan 2 mg dose of warfarin?● 3 ways
● 1 tab of a 2 mg tablet● ½ of a 4 mg tablet
4 mg blue
5 mg peach g
● 2 tabs, each 1 mgAlthough the med tray is in unit-dose packets, it is a good opportunity for
6 mg teal
7-1/2 mg yellow
packets, it is a good opportunity for teaching patients who are going home on warfarin.
10 mg white (Dye Free)
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MedPass, charting, and F/U
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MedPass, charting, and F/U
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I Wrap-upWarfarin is a dangerous drug
Bleeding is a risk and patients may not complain or show symptoms of internal bleeding
Warfarin is a complicated drug regimenFrequent dose change, many drug and food interactions, narrow therapeutic window between b fi i l d h f l ff tbeneficial and harmful effects
Team work and good communication with physicians and between shifts with physicians and between shifts with everyone aware of policy and procedures is crucial to warfarin safetyis crucial to warfarin safety
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IPRO provides a full spectrum of healthcare assessment and improvement services that foster the efficient use of resources and enhance healthcare quality to achieve better patient outcomes.
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.
9SOW-NY-THM6.2-10-05
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For more information
Dianne Roux-Lirange, PhD, MSRNPerformance Improvement Coordinator
M di Ph P j tMedicare Pharmacy ProjectsHealthcare Quality Improvement Program
(518) 426-3300 ext 106(518) 426-3300 ext. [email protected]
CORPORATE HEADQUARTERS1979 Marcus AvenueLake Success, NY 11042-1002REGIONAL OFFICE20 Corporate Woods BoulevardAlbany, NY 12211-2370
www.ipro.org
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