Question

Mrs. Jay, a 73 year old female, has been admitted to the hospital for treatment of a deep vein thrombosis in her right calf. Her PMH includes hypertension. She has been taking Capoten 12.5 mg BID with good control of her pressure.  She is ordered on bedrest with the following orders:

Heparin 5000units IV bolus, followed by a heparin drip of 25,000units in 250ml to infuse at 1000 units per hour. Follow heparin protocol that includes obtaining a stat aPTT 6 hours after initiation and 6 hours after any dose change.

After three days, the physician orders Warfarin (Coumadin) 2mg po daily.  Mrs. Jay asks why she needs to take Coumadin and the heparin.

1. How will you respond to her?

2. How does Coumadin work? What is the difference between Heparin and Coumadin?

3. What lab value will be monitored while on Coumadin? What is a therapeutic range?

4. What is the antidote for Coumadin overdose?

5. What are some nursing considerations for a patient taking anticoagulants?

6. Develop a detailed teaching plan for Mrs. Jay regarding taking Coumadin when she goes home.

Answer 1

1. I will provide answer for that is heparin is anticoagulant used concurrently for five days to prevent the thrombus propagation in the body. It can be given either through Intravenous or via subcutaneous and patient need to monitored for heparin level in the body by monitoring the activated partial thromboplastin time.If she had a new clot heparin is given along with another anticoagulant that is with coumadin (Warfarin) because warfarin takes 5 to 7 days to show its effect and it is a pill that patient can be prescribed by the doctor to take at home. Once warfarin was fully active after the certain period,heparin was stopped and patient will take warfarin can take alone.The major side effect for heparin is bleeding.

2.Coumadin (Warfarin sodium):It is anticoagulant that works by blocking the reformation of vitamin K epioxide by inhibiting the synthesis of vitamin K dependent clotting factors that include prothrombin (factor 2),Stable factor (factor 7) and plasma thromboplastin factor(9) and anticoagulant proteins C and S.

Difference between Coumadin and heparin:

Heparin	Coumadin
It is direct anticoagulant that is mixture of high molecular weight sulfated monosaccharides	It is indirect anticoagulant and a organic compound
It inactivates the thrombin and factor Xa	It inhibit the synthesis of clotting factors
It can be given either through IV or SC	It can be given per oral
It can be eliminated through renally	It can eliminated through hepatic
Monitor anti thromboplastin time	Monitor prothrombin time
Antidote for overdose:Protamine sulfate	Antidote for overdose :Phytomenodione

3.Monitoring parameters:

• International normalized ratio (INR) should be monitored daily untill for stablized to the therapeutic range and then periodically for every 1 to 4 weeks.When two anticoagulants were given the effect the INR value.Patient who have high risk of bleeding may require more frequent INR testing.
• INR upto 12 weeks results will provide the dose adjustment for INR therapeutic range of above or below 0.5.
• For adults and pediatric therapeutic range is 2 to 3
• For mechanical mitral value and undergoing percutaneous mitral ballon valvotomy target INR is 2.5 to 3.5.

Therapeutic range is 2 to 3 INR for people taking warfarin for deep vein thrombos and atrial fibrillation.

4.Antidote for Coumadin overdose is Phytomenodione (Vitamin K1).

5.Nursing considerations:

• Heparin is narrow therapeutic index and have a increased risk for bleeding and heparin induced throcytopenia and laboratory monitoring is needed.Bleeding is major side effect that may seen from any route that is gum bleeding,epistaxis, hematuria, melena. Undiagnosed bleeding may lead to cardiovascular collapse.if any overdose antidote should be administered.
• International normalized ratio and prothrombin time,activated clotting time plasma concentration can be monitored for the anticoagulants.
• Nurse should guide about diet while taking anticoagulants and about the medication and side effects.

6.Patient education for Mrs.Jay when she goes home:

• If any bleeding symptoms observed during immediately consult the physician.
• Side effects of coumadin may include nausea,vomiting,dermatitis,rash,pruritus and abdominal pain.
• Avoid salicylates such as aspirin because that may leads to drug interaction.
• If she missed to take dose take as soon as possible on the same day.
• Warfarin has potential drug and food interactions such as acetaminophen,metronidazole and omeprazole that may decrease international normalized ratio and avoid vitamin K food that may decrease the anticoagulant action.