Nursing Clinical Practice Guide
Clinical Scenario: Mr. Johnson, a 68-year-old with a history of atrial fibrillation, is on warfarin 5 mg daily. During your morning assessment, he mentions he has noticed some new, large bruises on his arms without remembering any injury. His vital signs are stable. You check his morning lab results: PT 48 seconds, INR 7.1.
Nursing Intervention Strategy:
- Immediate Assessment & Safety:
- ABCs & Neurological Check: Quickly assess airway, breathing, circulation. Perform a focused neurological assessment (LOC, pupil response, motor strength) to rule out intracranial bleed.
- Bleeding Survey: Check gums for bleeding, inspect stool for melena (tarry black stool), ask about hematuria (blood in urine), nosebleeds, or unusual pain (which could indicate internal bleeding).
- Fall Prevention: Institute fall precautions immediately. Keep the bed in low position, ensure call light is within reach, and assist with ambulation.
- Immediate Actions:
- Hold the Medication: Do not administer the scheduled warfarin dose.
- Notify the Provider STAT: Report the critical INR, the patient's symptoms (bruising), and your assessment findings clearly using SBAR (Situation, Background, Assessment, Recommendation).
- Prepare for Interventions: Anticipate orders for Vitamin K (oral or IV) and/or Fresh Frozen Plasma (FFP) transfusion. Have emergency equipment readily available.
- Ongoing Monitoring & Education:
- Monitor vital signs frequently (especially blood pressure for hypotension from bleeding).
- Re-check INR as ordered after reversal agents are given.
- Once stable, reinforce education: "Mr. Johnson, it's very important to have your blood checked regularly. Let's also review which foods are high in Vitamin K and why keeping a consistent intake is crucial."
Patient Safety and Precautions:
- Vitamin K Administration: IV Vitamin K must be given slowly to avoid anaphylactoid reactions. Subcutaneous administration can cause erratic absorption.
- FFP Transfusion: Follow standard blood transfusion protocols: verify order, check blood product with another nurse, use a filtered IV line, monitor for transfusion reactions (fever, chills, itching, dyspnea).
- Drug Interactions: Always review the patient's medication list. Common culprits that increase INR include antibiotics (e.g., Bactrim), antifungals (e.g., Fluconazole), NSAIDs (e.g., Ibuprofen), and amiodarone.
Nursing Procedure & Medication Flow
Managing a Critically High INR:
1.
Assess: Patient stability and signs of active bleeding.
2.
Hold: The next dose of warfarin.
3.
Notify: The physician/provider immediately with lab results and assessment.
4.
Prepare: For possible administration of:
*
Vitamin K (Phytonadione): Often given orally (5-10 mg) for non-urgent reversal. For serious bleeding or very high INR, IV route may be used (give slowly over 20-30 minutes).
*
Fresh Frozen Plasma (FFP): Provides immediate clotting factors. Dose is typically 10-15 mL/kg. Must be ABO compatible.
5.
Monitor: Re-check INR in 6-12 hours after intervention. Continue frequent assessments for bleeding.
6.
Educate: Once resolved, review factors that may have caused the elevated INR (diet change, new medication, illness).
A Word from Your Senior Nurse
"Managing anticoagulation is a balancing act. We walk a tightrope between preventing clots and causing bleeding. Your vigilant assessment skills are the safety net. Don't just chart that lab value and move on. Look at your patient! A bruise here, a complaint of dizziness there—these are the clues that, combined with a critical lab value, tell the real story. In clinicals and on the NCLEX, always think: 'Is my patient safe right now?' If the answer is no because of a lab value like an INR of 6.8, then your next action is crystal clear:
Stop the drug, see the patient, call the provider. That's the heart of safe, effective nursing."