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5/13/2018 Elevated INR and Bleeding Ppt-1 - slidepdf.com
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By:
Ranjeetha Reddy RN
6th
floor
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Mr. Smith is an 80 year old Caucasian malepatient who presented to the ER with thefollowing:
cool, clammy extremities,
tachycardia HR 150 and BP of 90/60 mm Hg
complaining of abdominal discomfort and distention
nose bleed X3 in the past 3 days.
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The following orders were completed in ER
IV started and 1 Liter of normal saline bolus given
O2 per nasal cannula
Labs drawn and sent:
Blood cultures, CBC with differential, electrolytes,type and cross, renal and liver profile, and internationalnormalize ratio(INR) test, and prothrombin time (PTT).
Ultrasound of the abdomen performed
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Lab results were
hemoglobin and hematocrit of 9.0/27.5
normal white count and platelet count
INR of 9 (far beyond the normal range).
While waiting for CT of abdomen results, thepatient was transferred to 6th floor.
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Mr Smith was transferred toMS . He has a history ofhypertension, atrial fibrillation , and a stroke 1 year ago
Immediate assessment:
alert, oriented X 3 oxygen saturation of 92% and a respiratory rate of 26.
Medications include: 50mg of Atenolol, 20mg ofLisinopril, 75mg of Plavix, and 5mg of Coumadin.
U
ltrasound results:.
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Review information communicated in the handoff INR > 9
H/H: 9.0/27.5 V/S; Tachycardic and hypotensive
Abdominal discomfort and distention
Immediate actions needed
Notify Charge nurse of patient complications MD notification of critical test results and assessment
Obtain results of abdominal ultrasound
Call rapid response
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When communicating patient information to theMD utilize SBAR SITUATION: Reason for communication BACKGROUND: H istory of current situation
ASSESSMENT: Physical findings RECOMMENDATION: W hat needs to be done?
Hand off Communication; ADM 418 ( 7/2010 updated)
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Your patientMr. Smith in room 6430 was transferredfrom the ER. He is an 80 yo Caucasion male withcomplaints of abdominal pain and distention, 3 nose
bleeds in the past 3 days. He has a history ofhypertension, atrial fibrillation and a stroke 1 yearago.
Home medications include: Coumadin 5mg.Daily,Atenolol 50mg, Lisinopril 20mg and Plavix
75mg Lab results are as follows: INR 9.0, H/H 9.0/27.5
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He has a history of hypertension, atrial fibrillationand a stroke 1 year ago.
Home medications include: Coumadin 5mg.D
aily,Atenolol 50mg, Lisinopril 20mg and Plavix75mg
Lab results are as follows: INR 9.0, H/H 9.0/27.5
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Vital Signs: BP- 85/55, Pulse- 135, Respirations- 26,Temp- 96.0
The patient·s mental status is: Alert and oriented to
person, place, and time. Lethargic but conversantand able to swallow
The skin is: Pale and dry, Extremities are cold
Complaining of constant abdominal discomfort and
progressive distention of abdomen. The patient is on 2 Liters of oxygen, saturating at
95%.
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The patient seems to be unstable and I amconcerned that he may be bleeding internallybecause of the elevated INR level and his
symptoms. I am concerned that he may bedeteriorating .
I would like you to come and reevaluate thispatient and orders for the following:
Vitamin K
Possibly repeat labs
transfer pt to the ICU,
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Warfarin is an oral anticoagulant mostfrequently used to control and preventthromboembloic disorders..
Warfarin exerts its action by inhibiting vitaminK dependent coagulation factors(II, VII, IX, X);
Warfarin inhibits the synthesis of natural
anticoagulants in the blood, protein C and S.
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The target international normalized ratio(INR) is maintainedaround 2-3.
Common adverse effects of Warfarin Spontaneous bleeding is the most common Bleeding is usually subcutaneous or intra muscular.
Intracranial, retroperitoneal, and gastrointestinal bleeding can be lifethreatening.
Various factors determine the bleeding complications of warfarin.These include : older age, dose, duration of therapy, drug interaction and Occult disease. Many drugs interact with warfarin, the common being NSAID. In fact, the
most common cause of bleeding secondary to warfarin is drug interaction.
It has also been shown that warfarin, when combined withantiplatelet drugs like Clopidogrel have higher incidents ofbleeding.
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Lab Critical Results
Once a critical lab test result is identified, the resultsare entered into the LIS system and a call is placed tothe patient·s nurse.
The nurse or a licensed responsible caregiver will writethe inoformation down and read back the critical testresults.
The nurse will immediately call the patient·s physician.
The time frame for the communication of critical labtest results to the appropriate licensed care provider is60 min.
Reporting Critical Tests and Results; PCPS 014 ( 7/1/2010 updated)
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Diagnostic Imaging Critical Results The radiologist will call the ordering physician and
give a verbal report. The turn around time for the licensed responsible
care giver notification of critical imaging results is15 min.
Pathology Services- Critical Tests The pathologist will notify the ordering or other
responsible physician of results of critical anatomicpathology tests. The lab personnel will notify the nurse or licensed
responsible care giver of results of critical clinicallab tests.
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Increase heart rate or respirations decrease blood pressure nose bleeds, blood in sputum, urine or stools,bleeding gums increase abdominal girth
bleeding from superficial cuts, wounds or ulcer which maybe prolonged oozing from venipuncture or arterial sides; unusually heavy menstrual bleeding; unexplained
echymosis; hematoma or petachiae on the skin
Hematuria(most common) Intracranial hemorrhage(most devastating) spinal epidural hematoma, retroperitoneal hemorrhage(only 2/3 have abdominal pain);
hemopericardium, hemothorax, and hemarthrosis
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Grey-Turner·s sign
flank echymosis
Cullen·s sign
Periumbilical echymosis
Fox·s sign
Ecchymosis of the upper thigh with a sharpdemarcation below the inguinal ligament
Bryant·s Blue scrotum sign
scrotal echymosis
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Hand off communication is the act of exchanging currentpatient information between health care providers, allowingan opportunity for question.
SBAR(Situation, Background, Assessment,Recommendation) is the recommended approach for handoff communication between health care providers whetherthe communication takes place during an internal transfer, aprocedural transfer, a shift to shift transfer, or whenspeaking with a physician.
Unit-specific report tools are available for hand offcommunication as well as tools for implementation of theSBAR communication process.
The clinical summary is the universal tool in Method toutilize when providing handoff
Hand off Communication; ADM 418 ( 7/2010 updated)
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When a member of the health care team is concernedabout the condition of a patient or feels that a patientneeds immediate intervention, he/she may contact therapid response team (RRT) for assistance.
The RR
Tis mobilized by dialing the emergencynumber (77777) and requesting the team respond to
room location. The nurse will call the attending physician to inform
him/her of the change in the patient·s condition. The RRTwill respond within 5 min. The SBAR communication technique will be used
between the nurse, RRT, and physician.
Rapid Response Team; PCPS 407 (9 /1/2010 updated)
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The RRT will assess the situation and follow ACLS protocolif required.
The RRT will strive to have the assessment completed by thetime the attending physician returns the call so thatpertinent information can be relayed to the physician andorders given as indicates.
The attending physician will determine the disposition ofthe patient i.e. remain on the unit or be transferred to thehigher level of care.
The RRT may use the situation to educate/mentor thebedside nurse or refer the issues to the clinical nursemanager for follow-up education.
Any assessment/treatment initiated as a result of RRT callwill be documented in the appropriate section of medicalrecords.
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Procedure
When a nurse or other licensed professional has aquestion or concern regarding the care of a patient,
the following steps should be followed:1. The healthcare professional or their supervisor or charge
nurse should communicate such questions or concerns tothe physician and request clarification or assurances.
2. In the event the matter is not being resolved, the physician
should discuss the questions with the healthcareprofessional·s supervisor or charge nurse. This supervisorand physician will arrive at an appropriate resolution thatmeets the needs of the patient in a timely fashion.
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If, in the unusual circumstance, the situation is not resolvedby steps 1 and 2 above, the healthcare professional willcontact the department director or administrativecoordinator. Concurrently, the physician will seek advicefrom another physician with appropriate clinical expertise
and discuss a resolution with the department director oradministrative coordinator. If prior efforts do not resolve the matter, The department
director or administrative coordinator will attempt tocontact the following, in order, until resolution is achieved. Medical director of the unit or department chairman(as
appropriate) President of the medical staff If any of these are not immediately available, the next line should
be called. If the president of the medical staff is contacted, then theadministrator on-call should also be contacted.
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When you are taking care of patient with elevatedINR required for frequent monitoring of warningsigns like
Increase Heart rate or Respirations, decreased blood pressure.
Nose bleed & bleeding gums. blood in sputum , urine ,or stool. Bleeding from venipuncture , IV sites, prolonged bleeding from
superficial cuts & wounds.
Nurses need to use Chain of Command in differentlevels to Escalate the problems in patient care.
When a Nurse has concerns regarding the care of a patient, inform
Charge Nurse about patient complication. Charge Nurse should communicate with Physician with concerns and
clarifications. If a problem is not resolved need to contact -FloorManager ²
Department Director ² Department Chairman- President of theMedical staff.
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Always need to take assistance of RapidResponse Team by activating emergencynumber (77777).
When a Nurse or a member of Health Care team is concernedabout the condition of a patient or feels that a patient needsimmediate intervention.
The Rapid Response Team will respond within 5 min.
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1. GarciaD, Regan S, CrowtherM, Hughes RA, Hylek EM. Warfarinmaintenance dosing patterns in clinical practice: Implications for saferanticoagulation in the elderly population. Chest. 2006: 127 (6): 2049-2056
2. Du Breuil Al, urmland EM. Out patient management of anticoagulationtherapy, Arm Fam Physician. 2007; 75 (7): 1031-1042
3. Lip GYH. Anticoagulation in the elderly.Up to date website.http://www.uptodate.com. Accessed: April 2, 2009
4. LevineM, Raskob G, Beyth R, etal. Hemorrhagic complications ofanticoagulant treatment. Chest. 2004; 126 (3): 287S-310S
5. Kucher N, Castellano LR, Quiroz R, Koo S, Fanikos J, Goldhaber SZ et al.
Time Trends in warfarin- associate hemorrhage. AM J cardiol 2004; 94:403-6
6. Muralikrishna,Thomas, Haray. Warfarin induced hemorrhagicinfarction of small bowel. Int J Lab Hematol 1998; 20: 319-20.
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7. Reporting Critical Tests and Results; PCPS 014 ( 7/1/2010 updated)
8. AnticoagulantManagement Program; PCPS 215 ( 11/1/2008 updated)
9. Hand off Communication; ADM 418 ( 7/2010 updated)
10. Rapid Response Team; PCPS 407 (9 /1/2010 updated)11. Legally Speaking: Going up the chain of command.Diana W.Morgan,
RN,MS, RNWeb Archive, Jun. 1, 2003