Elevated INR and Bleeding Ppt-1

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By:

Ranjeetha Reddy RN

6th

floor



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.



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



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.



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:.



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



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)



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



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



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%.



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,



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.



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.



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)



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.



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



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



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)



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)



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.



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.



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.



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.



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.



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.



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

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Elevated INR and Bleeding Ppt-1

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