Flowsheet of Coumadin Management - Weebly



Flow-sheet of Anticoagulation Management

[pic]

[pic]

[pic]

Table A: Intensity of Warfarin Anticoagulation

|Indication |INR Range |Target |Suggested Duration |

|Prophylaxis of venous thrombosis (total hip replacement, |2.0-3.0 |2.5 |1 month |

|total knee arthroplasty and hip fracture surgery) | | | |

|Treatment of venous thrombosis or PE |2.0-3.0 |2.5 |3-6 months |

|Acute myocardial infarction (to prevent systemic |2.0-3.0 |2.5 |3-6 months |

|embolism) | | | |

|Atrial fibrillation and/or flutter |2.0-3.0 |2.5 |Indefinite |

|Certain patients with thrombosis and antiphospholipid |3.0-4.0 |3.5 |Indefinite, defer to provider |

|antibody syndrome | | | |

|Tissue and mechanical heart valves |Variable |Variable |Refer to cardiology for INR |

| | | |management |

Source: University of Michigan Health System.  (2009, June 15).  Anticoagulation management service for health professionals: Intensity of Warfarin anticoagulation for different thrombotic disorders.  Retrieved from

Table B: Anti-coagulation management assessment questions

|Assessment questions: |Further assessment if indicated |

|Is the patient taking the medication correctly? |If no, document how was being taken and take into consideration |

| |for how this may affect INR level |

|Is the patient feeling well? |If no, see table C below |

|Is the patient following their prescribed diet? |Review changes in vitamin K rich food |

|Has the patient had any recent changes to medications? |Started on antibiotics? Assess for any other new medications that|

| |may interact with Coumadin |

|Does the patient have any bruising or bleeding? |If yes, see table C below |

|Has the patient been hospitalized since the last PT/INR? |Coumadin dosing changed in hospital? Last INR? |

|Is the patient taking any OTC pain relievers? |Specifically any NSAID or aspirin |

|Is the patient taking any multivitamin or dietary supplement |Does multivitamin contain vitamin K? Does patient take regularly |

|(i.e.: Ensure)? |or is this new? |

|Does the patient have any dental or other surgery scheduled in |If yes, see table G |

|the near future? | |

*Assessment questions accessible through NextGen: Anti-coagulation dosing module: management tab: relevant history

Table C: Anti-coagulation specific review of symptoms

|System |Signs and Symptoms |

|Constitutional |Fatigue, fever, weight loss |

|Cardiovascular |Bilateral or lower extremity edema, chest pain, palpitations |

|Hematological/Lymphatic |Abnormal bleeding, easy bruising, oral bleeding, petechiae |

|HEENT |Bleeding gums, epistaxis, tinnitus |

|Gastrointestinal |Black tarry stools, blood in stool, change in appetite, |

| |dyspepsia, hematemesis, melena |

|Neurological |Headache, speech changes, vertigo |

|Respiratory |Dyspnea, dyspnea on exertion, |

|Genitourinary |Dark urine, dysuria, hematuria |

*Assessment questions accessible through NextGen: Anti-coagulation dosing module: management tab: specialty specific ROS

Table D: Warfarin Initiation Algorithm

Days 1-3

| |Day 1 |Day 2 |Day 3 |

|Recommended dose |5mg |5mg |5mg |

|Next INR |1-3 days |1-3 days |1-3 days |

Days 4-7

|INR result |Day 4 |Day 5 |Day 6 |Day 7 |

|INR 2.2-4.9 |Hold |2.5mg |2.5mg | |

|INR >5 |Consult provider | |

|Next INR |1-3 days |1-3 days |1-3 days | |

Notes:

1. Most patients should receive a prescription for 2.5mg or 5mg tablets to be dosed at bedtime.

2. Consider starting with 2.5mg if patient is elderly, malnourished, has liver disease or high bleeding risk.

3. *Consider giver 7.5mg on Day 4 if INR is 1.5 consider giving vitamin K 1.25mg po.

• Resume warfarin immediately after procedure

*LWMH Bridging therapy recommended in patients at moderate-to-high risk of thromboembolism:

• Mechanical heart valve

• Stroke or TIA within past 6 month

• CHADS2 score of 3 or greater*

• Atrial fibrillation with valvular heart disease

• VTE within past 3-12 months

• Rheumatic valvular heart disease

• Severe thrombophilia or non-severe thrombophilic conditions

Notes:

1. Contact physician to discuss possible bridge therapy and time period to check pre-procedure INR values.

2. Some procedures do not require alternation of anticoagulation is not required. These include: fillings, crowns, bridges, root canal, routine cleaning, single or double tooth extraction, scaling or polishing, minor dermatologic procedures, cataract removal. All patients’ undergoing these procedures should have an INR performed within 24 hours before the procedure (same day preferable). If the INR is >3.5, consideration should be made to delay the procedure in consultation with the managing provider, dentist, or surgeon.

3. LMWH dose (enoxaparin 1mg/kg or dalteparin 120units/kg) every 12 hours recommended at 7am and 7pm. If patient has CrCl under 30mL/min, dose (same as above) once daily recommended at 7am.

4. *CHADS2 score based on 1 point each for CHF, hypertension, age over 75 years, diabetes and 2 points for TIA or stroke.

5. Discontinue LWMH post-procedure when one INR value is 2.5 or greater or two consecutive INR values are over 2.

Source: Spectrum Health The Medical Group. (2011). Bridging Algorithm; Dosing Algorithm for LMWH pre- and post- procedure. Grand Rapids, MI: Anticoagulation EOC Design Team.

Michigan Anticoagulation Quality Improvement Initiative.  (2009). Flowchart for LMWH “Bridging.”  Retrieved from

References

Fay, W. (2004, July 28). Management of Warfarin for invasive procedures. Retrieved from

McKenzie, O. (2000). Evolution of a nurse-managed Coumadin clinic. Nursing Spectrum -- New York & New Jersey Edition, 12A(8), 20.

Medical Associates Clinic and Health Plans. (2012, December). Clinical practice guideline for anticoagulation management. Retrieved from

Michigan Anticoagulation Quality Improvement Initiative.  (2009). Flowchart for LMWH “Bridging.”  Retrieved from

Nochowitz, B., Shapiro, N., Nutescu, E., & Cavallari, L. (2009). Effect of a Warfarin adherence aid on anticoagulation control in an inner-city anticoagulation clinic population. Annals Of Pharmacotherapy, 43(7-8), 1165-1172. doi:

Spectrum Health The Medical Group. (2011). Bridging algorithm. Grand Rapids, MI: Anticoagulation EOC Design Team.

Spectrum Health The Medical Group. (2011). Warfarin initiation algorithm: Dosing algorithm for INR.  Grand Rapids, MI: Anticoagulation EOC Design Team.

Spectrum Health The Medical Group. (2011). Warfarin initiation algorithm: Dosing algorithm for INR range 2-3.  Grand Rapids, MI: Anticoagulation EOC Design Team.

Spectrum Health The Medical Group. (2011). Warfarin initiation algorithm: Dosing algorithm for Warfarin-naïve patients.  Grand Rapids, MI: Anticoagulation EOC Design Team.

University of Michigan Health System.  (2009, June 15).  Anticoagulation management service for health professionals: Intensity of Warfarin anticoagulation for different thrombotic disorders.  Retrieved from

University of Michigan Health System. (2013). Anticoagulation service for health professionals. Retrieved from

-----------------------

Dosage and length of therapy dependant upon diagnosis?

(see table A below)

Mechanical heart valve, arteriole emboli, etc

INR target range: 2-3

-See table B for assessment

-check INR

INR to be managed by cardiologist

Check INR in 1-3 days

Continuation of therapy

Start of therapy and LMWH bridging:

INR 5: see table F below

INR result

Supra-therapeutic:

-stop LMWH

-see table D for Coumadin dosing

Therapeutic:

Has pt received >5 days of combined heparin/

warfarin?

Yes:

-continue LMWH one more day, then DC

-see table D for Coumadin dosing

Sub-therapeutic:

-continue LMWH

-see table D for Coumadin dosing

No:

-continue LMWH until pt completes 5 days of combined heparin/warfarin, then DC LMWH

-see table D for Coumadin dosing

-Check INR in 1-3 days

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download