# A 72-year-old client on warfarin for atrial fibrillation has serial INR results and bleeding observations recorded. Review the trend and choose the priority interpretation and action.

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> subject: Dosage Calculations  
> category: PPT

## Question

A 72-year-old client on warfarin for atrial fibrillation has serial INR results and bleeding observations recorded. Review the trend and choose the priority interpretation and action.

| Time | Data |
| --- | --- |
| Day 0 (clinic visit) | INR 2.5 (target 2.0-3.0), no bleeding, on warfarin 5 mg daily |
| Day 7 | INR 4.1, mild gum bleeding when brushing teeth, no other bleeding |
| Day 10 | INR 6.8, frank epistaxis lasting 30 minutes, mild fatigue |
| Day 12 (ED) | INR 9.2, gross hematuria, two episodes of melena, BP 102/64, HR 108 |

Q1. Across the four time points, the trend is best described as which of the following?

Improving
Stable
Deteriorating with major bleeding

Q2. Which of the following is the priority response in the ED on Day 12?

Continue the current warfarin dose and recheck INR in 24 hours
Hold warfarin, give vitamin K, prepare 4-factor PCC or FFP, type and screen, and notify the provider
Switch the client to enoxaparin and discharge home with follow-up next week
Give a single oral dose of vitamin K only and discharge with usual warfarin

## Explanation

Trend interpretation
INR climbs from 2.5 to 9.2 across 12 days while bleeding progresses from none to gum bleeding to epistaxis to hematuria and melena. The trajectory is deteriorating with major bleeding. Hold warfarin, give vitamin K, prepare blood products, and notify the provider immediately.

## In-depth explanation

Step 1 — Read INR
Therapeutic INR for atrial fibrillation is 2.0 to 3.0. Day 0 INR 2.5 is in range. Day 7 INR 4.1 is supratherapeutic with mild bleeding. Day 10 INR 6.8 is markedly elevated with active epistaxis. Day 12 INR 9.2 with hematuria and melena is major bleeding with critical INR.

Step 2 — Read bleeding
Mild gum bleeding → frank epistaxis → hematuria and melena is a progressive bleeding cascade. Melena and hematuria mark major bleeding requiring reversal.

Step 3 — Choose priority response
For major bleeding with INR over 9 the standard is: hold warfarin, give vitamin K (IV for major bleeding), prepare 4-factor PCC or fresh frozen plasma, type and screen, and notify the provider. Continuing warfarin or merely repeating INR delays definitive care.

Key concept
NCLEX rewards reading INR alongside the patient. Lab plus bleeding equals action; lab alone may not.

## Clinical scenario

Scenario
72-year-old female on warfarin for atrial fibrillation (target INR 2.0 to 3.0). Serial clinic and ED visits over 12 days produce both INR values and bleeding observations.

Concern
The INR is rising rapidly while bleeding progresses. The most recent ED visit shows hematuria and melena with INR 9.2.

Background
Anticoagulation guidelines distinguish supratherapeutic INR without bleeding from major bleeding, which always warrants reversal.

## Key concepts

- **Therapeutic INR window** — For most atrial fibrillation indications, target INR is 2.0 to 3.0. Mechanical mitral valves target 2.5 to 3.5.
- **Major bleeding criteria** — Bleeding that is fatal, occurs at a critical site (intracranial, retroperitoneal, intraocular), causes hemoglobin drop of 2 or more, or requires transfusion. Always warrants warfarin reversal.
- **Warfarin reversal options** — Vitamin K (oral if no bleeding, IV for major bleeding); 4-factor PCC for rapid reversal in major bleeding; fresh frozen plasma is an alternative when PCC is unavailable.

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