# A 65-year-old client takes chronic warfarin for atrial fibrillation and had an embolic stroke 2 months ago. Before elective hip replacement, the perioperative team has prescribed LMWH bridging after an individualized high-thromboembolic-risk assessment. Which nursing actions are appropriate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368109&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 65-year-old client takes chronic warfarin for atrial fibrillation and had an embolic stroke 2 months ago. Before elective hip replacement, the perioperative team has prescribed LMWH bridging after an individualized high-thromboembolic-risk assessment. Which nursing actions are appropriate? Select all that apply.

1

Resume full-dose therapeutic anticoagulation immediately in the post-anesthesia care unit regardless of surgical hemostasis or bleeding risk

2

Administer subcutaneous enoxaparin in the abdomen at the prescribed dose, rotate injection sites, and avoid aspirating or massaging the site

3

Discontinue all anticoagulation only 24 hours before surgery because warfarin clears completely within that time

4

Stop warfarin approximately 5 days before surgery as ordered, monitor the INR until it reaches the procedural target, and document the trend

5

Hold the last therapeutic LMWH dose at least 24 hours before surgery, or about 12 hours for a prophylactic dose, and communicate the exact last-dose time

6

Continue warfarin until the morning of surgery and add LMWH to maintain dual anticoagulation until incision

## Explanation

Current guidance recommends against routine heparin bridging for most clients with atrial fibrillation because bleeding risk usually outweighs benefit. This scenario explicitly states that the perioperative team selected bridging after individualized assessment of a recent embolic stroke. When bridging is ordered, stop warfarin about 5 days before surgery and follow the ordered INR target (Choice 4). Administer enoxaparin correctly without aspiration or massage (Choice 2). Hold therapeutic LMWH at least 24 hours before surgery and communicate the last-dose time; prophylactic dosing commonly uses a shorter interval per protocol (Choice 5). Do not continue warfarin through surgery with added LMWH (Choice 6), do not assume warfarin clears in 24 hours (Choice 3), and restart therapeutic anticoagulation only after adequate hemostasis and according to procedural bleeding risk (Choice 1).

## In-depth explanation

Perioperative Bridging Anticoagulation
1. Risk stratification: bridge moderate-high VTE/AFib stroke risk; not low risk
2. Warfarin hold: stop ~5 days preop; daily INR until <1.5
3. LMWH bridge: therapeutic enoxaparin SC starts ~3 days preop
4. Last LMWH dose: hold ≥24 hr preop (therapeutic) or ~12 hr (prophylactic)
5. Postop resumption: 24-72 hr based on hemostasis + bleeding risk

SC LMWH Technique
- Site: abdomen (anterolateral, 2 inches from umbilicus)
- Rotate sites with each dose
- Do NOT aspirate or massage — risk of hematoma
- 90° angle; pinch fold of skin

Common Pitfalls
- Continuing warfarin to OR morning + adding LMWH (over-anticoagulation)
- Stopping anticoagulation 24 hr before surgery without bridging (thromboembolism)
- Full-dose immediate postop resumption (hemorrhage)

Memory Tip
"5-3-1: 5 days off warfarin, 3 days bridge LMWH, 1 day (24 hr) hold last LMWH"

## Clinical scenario

Scenario
65 yo, chronic warfarin (AFib), planned hip replacement in 5 days, on enoxaparin bridge.

Bridging Timeline
Day -5: stop warfarin
Day -4 to -3: continue daily INR; start LMWH when INR drops
Day -3 to -1: full therapeutic enoxaparin SC
Day -1 (≥24 hr preop): hold last therapeutic LMWH
Day 0: surgery
Day +1 to +3: restart anticoagulation based on hemostasis

SC Enoxaparin
- Abdomen, rotate sites
- 90° pinch fold; do NOT aspirate or massage

Avoid
- Stacking warfarin + LMWH to OR morning
- 24-hr abrupt discontinuation without bridging
- Immediate full-dose PACU resumption

## Key concepts

- **Bridging Anticoagulation** — Perioperative strategy in moderate-to-high thromboembolic risk clients on chronic warfarin: warfarin is held while short-acting parenteral anticoagulation (typically therapeutic LMWH such as enoxaparin) covers the gap. Indicated for AFib with elevated CHA2DS2-VASc, mechanical heart valves, recent VTE. Reduces thromboembolism while warfarin effect is reversed for surgery.
- **Subcutaneous LMWH (Enoxaparin) Administration** — Subcutaneous injection technique: anterolateral abdomen 2 inches from umbilicus, rotate sites, 90° pinch-fold technique, do NOT aspirate, do NOT massage after injection. Common adverse effects: bleeding, hematoma, heparin-induced thrombocytopenia (HIT — monitor platelet count). Dose: prophylactic 40 mg SC daily; therapeutic 1 mg/kg SC q12h or 1.5 mg/kg SC daily.
- **Perioperative Anticoagulation Timing** — Standard timing: stop warfarin ~5 days preop with daily INR until <1.5; start LMWH bridge ~3 days preop; hold last therapeutic LMWH ≥24 hr preop (~12 hr if prophylactic dose) and document exact timing for the surgical team. Postoperative resumption is delayed 24-72 hr depending on hemostasis and surgical bleeding risk; therapeutic dosing is not given immediately in the PACU.

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