Question

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. 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 in K.N.'s case?

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.

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 international normalized ratio (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 laboratory 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?
.
6. What should K.N. have done to prevent this problem?

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?

You want to make certain K.N. knows what "hold the next dose" means. What should you tell him?
K.N. grumbles about all the laboratory tests but agrees to follow through.
What is 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. Paresthesia lower extremities
d. Bruising
CASE STUDY PROGRESS You know that sometimes the only needed action is to stop the warfarin 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 his anticoagulation information, the provider decides that K.N. will need to stop the warfarin 1 week before the surgery and in its place be started on enoxaparin therapy.
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. Inject two inches from belly button.

Answer 1

Answer

1- Normally heart contract and relax to a regular beat.In atrail fibrillation the both atria ( upper chambers) of the heart beat irregularly . This beating cannot effectively move blood in to the ventricles. Heart rate will be usually fast with this condition.

2- It is very effective at reducing the stroke in people with atrial fibrillation . Warfarin reduces the risk of a stroke by preventing blood clots forming as easily.

3- a)An INR is a type of calculation based on PT test.PT test - measures how long it takes for a clot to form in a blood sample.

b) INR range between 2 and 3 .

c) The PT/INR are used to monitor the effectiveness of the anticoagulant warfarin.

4- INR levels above 4.9 are considered critical values and increase the risk of bleeding .The chance of bleeding ( haemorrhage)inside the head increase significantly.

5- Proton- pump inhibitors (PPls) might reduce the risk of serious warfarin related upper gastrointestinal bleeding,but it may cause more side effects.

6-Always treat bleeding quickly. -Fat regular , healthy meals -Warfarin with target INR of 2-3