Question

Case Study: Atrial Fibrillation and Oral Anticoagulation

You are the nurse working in an anticoagulation clinic. One of your patients is K.N., who has a long-standing history of an irregularly irregular heartbeat (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?   
2. What is the purpose of the warfarin (Coumadin) in K.N.'s case?    

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.

3. What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of the INR?   
4. When you get the results, his INR is critical at 7.2. What is the danger of this INR level?  

The health care provider does a brief focused history and physical examination, orders additional lab tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped. The provider discovers that K.N. recently went to the local urgent care center for a sinus infection and had received a prescription for the antibiotic co-trimoxazole (sulfamethoxazole-trimethoprim) (Septra).

5.   What happened when K.N. began taking the antibiotic?   
6. What should K.N. have done to prevent this problem?
7. 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 PT/INR blood draw. Why do you tell K.N. to take the vitamin K?  

You want to make certain K.N. knows what “hold the next dose” means. What should you tell him?    

9. K.N. asks you why his PT/INR has to be checked so soon. How will you respond?    

K. N.'s INR the next day is 3.7, and the health care provider made no further medication changes. K.N. is instructed to finish the remaining 2 days of antibiotics and return 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?
11.   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 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

f. Unexplained abdominal pain      

12. What other patient education needs to be stressed at this time? (Identify two.)
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?    

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 anticoagulation protection by initiating low-molecular-weight heparin. After reviewing all of his anticoagulation 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.    

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 (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 is given.

e. H old extra pressure over the site after the injection.      

K. N. undergoes knee surgery without complications and does not experience any thrombotic events or bleeding episodes during his recovery.

Answer 1

Ans:(1)Atrial fibrillation (AF or A-fib) is an abnormal heart rhythm (arrhythmia) characterized by the rapid and irregular beating of the atrial chambers of the heart.

It is differ from normal heart rhythm because in which heart is beat too fast and HR is >350beats/min because of cardiac arrhythmias and Normal HR is 60-100beats /min in a health adult.

(2):-Purpose of Warfarin:-Warfarin is oral anticoagulant which is need in Atrial fibrillation because there is risk of ischemia and clotting occur due to rapid beating of atria.

(3)A prothrombin time (PT) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio (INR) is calculated from a PT result and is used to monitor how well the blood-thinning medication (anticoagulant) warfarin (Coumadin) is working to prevent blood clots.

PT results is: 11 to 13.5 seconds. INR of 0.8 to 1.1.

And in this case these value are rised or above normal range and purpose of this is to check risk of bleeding tendency .

(4)An INR Level of 7.2 is VERY HIGH and is much higher than your therapeutic INR range of 2-3. This meansyour blood is considered "dangerously thin".

(5)if there is sinus infection then antibiotics will help to resolve the problems and there is surgical management for this problem.

(6)Vitamin K is recommended because it is antidote of warfarin,if there is toxicity of warfarin then it resolve the problem.and vit k lower the bleeding tendencies and start clotting the blood .

(7)Warfarin and vitamin k are antagonist so both are not working together or these both together reduce effectiveness of each other.and K N advice to soon to do the blood investigation because there should be monitored bleeding and check effectiveness of vit k.

(8)s/s of bleeding are:

black terry stool,pain and swelling in new joints , unexplained abdomen pain,new onset of dizziness

(9) health education related to safety and prevent injury and dietary pattern.

(10)For knee replacement advice to tell about heart problems and warfarin therapy

(11)An anticoagulation effect generally occurs within 24 hours after drug administration. However, peak anticoagulant effect may be delayed 72 to 96 hours. The duration of action of a single dose of racemic warfarinis 2 to 5 days.

Adults: 1 mg/kg S.C. every 12 hours; or, 1.5 mg/kg S.C. once daily (at the same time every day) for 5 to 7 days until therapeutic oral anticoagulant effect (INR 2 to 3) has been achieved. Warfarin sodium therapy usually starts within 72 hours of enoxaparin injection.
(15) a. Monitor aPTT

c. The preffered site of enoxaparin is lateral abdomen fatty tissue

k.undergoes knee sur