A nurse is caring for a client prescribed Warfarin. Which nu… | MyMerci
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Medication AdministrationPPT
Question
A nurse is caring for a client prescribed Warfarin. Which nursing action is most appropriate regarding monitoring INR levels and maintaining consistent dietary vitamin K intake?
1Reassure the patient that taking tramadol 50 mg every 6 hours as needed with duloxetine is safe if she reduces alcohol to one drink per evening and monitors for drowsiness.
2Instruct the patient to discontinue duloxetine on her own while taking tramadol, because the combination can cause excessive sedation, and resume it when the back pain resolves.
3Recommend that the patient reduce her alcohol intake to one glass of wine daily, and then start the tramadol as prescribed without requesting liver function tests or a medication review.
4Notify the prescriber about the daily alcohol use and the new tramadol order, request liver function tests and a serotonin syndrome safety review, and discuss alternative analgesics.✓ Correct answer
Explanation
When administering Warfarin, key nursing considerations include monitoring patient status, checking critical laboratory values, and providing appropriate safety education. Unsafe practices such as stopping medications abruptly or doubling missed doses are incorrect.
Two-hit problem: alcohol + duloxetine = liver, duloxetine + tramadol = serotonin. Both must be addressed at once, not separately.
Clinical scenario
Scenario 60-year-old woman, MDD + fibromyalgia, on duloxetine 60 mg PO daily for 1 year. She drinks 2-3 glasses of wine nightly. Urgent care clinic ordered tramadol 50 mg PO q6h PRN for an acute lumbar strain. No prior LFTs available in chart; no signs of overt liver disease today, no jaundice, no asterixis, AOx3, vital signs stable. No SSRI/MAOI/triptan/St. John wort on the medication list.
Key concepts
Duloxetine hepatotoxicity — Boxed and labeled warning: avoid duloxetine in patients with substantial alcohol use or chronic liver disease. Hepatic injury usually occurs within 2 months but can be delayed; monitor LFTs if risk factors present and stop the drug for ALT >3x ULN.
Serotonin syndrome — Triad of mental status change, autonomic instability, and neuromuscular hyperactivity (clonus, hyperreflexia). Caused by stacking serotonergic drugs (SSRI/SNRI + tramadol/triptans/MAOI/St. John wort/linezolid). Treatment: stop offending drugs, supportive care, cyproheptadine in severe cases.
Tramadol cautions — Schedule IV opioid that is also an SNRI; lowers seizure threshold and contributes to serotonin syndrome with other serotonergic drugs. Avoid in seizure disorders, in children under 12, in post-tonsillectomy children, and in patients on high-risk co-medications without review.