1. This is
Great-Aunt Bea.
She came to the
local ER today
because she had a
nose bleed, but it
has now stopped.

2. While doing the
assessment, Great-Aunt
Bea states that her nose
stopped bleeding a few
hours ago, but she came
in anyway because she
still feels “bad.” She
states she was recently
diagnosed with
Pneumonia and has
been taking ATB, but
she is almost done with
it.

3. Her History
Great-Aunt Bea has:
CHF
Controlled A-Fib
Diabetes, Non-Insulin
Dependent
A Recent Diagnosis of
Pneumonia

4. Her Medications
Great-Aunt Bea takes:
Albuterol Inhaler
Coumadin
Furosemide
Metformin
Azithromycin (for the Pneumonia)

5. Allergies
No Known Allergies

6. Vitals:
Blood Pressure: 134/67
Respirations: 18 and
regular
Oxygen Saturation: 97% on
Room Air
Heart Rate: 62 and in A-Fib

7. Great-Aunt Bea looks uncomfortable.
She tells the nurse that she has noticed
blood in her urine, bright red blood in her
stool, and shows the Nurse a skin tear from
yesterday that is still scantly bleeding.
Also, Great-Aunt Bea states she had her
Coumadin Level checked the day she was
told she has Pneumonia. It was fine
according to her PCP.
The nurse’s first impression is that she stills
feels bad from the Pneumonia.

8. What does the Nurse do?

9. Do an EKG
She has a History of A-Fib,
the Doctor will want one.

10. Get a urine sample.
The Nurse notices that the urine
Great-Aunt Bea gives is pink

11. Start an IV
Draw enough labs for
a PT/INR
Blood Cultures

12. Xray Results
Return!!
Great-Aunt Bea still
has a small

13. The Labs Return!!!

14. Everything is normal
on her labs,
except.....
Great-Aunt Bea’s
INR is
13!!!!

15. Why is 13 a BIG Deal?
According to IU Health lab
standards, found on the Pulse Page
Normal INR ranges at 0.78 -
1.26
Therapeutic Level for a patient
on Coumadin is 2 - 3
Critical is > 5.0

16. But why was Great-Aunt
Bea’s so high?

17. Here’s why...
According to Micromedex,
found on the Pulse Page
“Concurrent use of
AZITHROMYCIN and
WARFARIN may result in an
increased risk of bleeding.”

18. The “Probable Mechanism”
according to Micromedex
The disruption of vitamin K
synthesis

19. So now what does the Nurse do?
Let the Physician know
Prepare to admit the
patient
The patient cannot go home
with an INR that high. She will
be at risk for hemorrhaging,
unknown internal bleeding,
and in case of trauma, a head
bleed.

20. Make sure that she has, at
least, a 20 gauge IV for
receiving blood products.
Also, avoid multiple blood
draws and IV starts.

21. MAKE HER A FALL
RISK!!!

22. If not already done so
Draw a tall purple for an ABO
Blood typing will be needed if the
Doctor orders Fresh Frozen
Plasma
Also, the lab label will need 2
readable RN signatures
This is according to the Blood
Products Protocol and
Procedure

23. Orders to Expect
According to Lexi-Drugs,
found on the Pulse Page
INR >10 with no evidence
of bleeding
Administer oral Vitamin
K

24. Again, according to Lexi-
Drugs
INR >10 with minor
bleeding
Administer oral vitamin K
more frequently

25. Major bleeding at any INR
elevation
Administer IV vitamin K
Prepare to give Fresh
Frozen Plasma

26. Other Interactions with Coumadin
Major Interactions that may enhance
Coumadin:
Pomegranate
Cranberry Juice
Fenugreek
Ginkgo Biloba
Green Tea
Alfalfa
Metronidazole (Flagyl)
Omega 3

27. Cont’ed
Penicillins
NSAIDS
Salicylates
Celery
Tramadol
Tricyclic Antidepressants (Elavil)
Alcohol
Allopurinol (used to treat Gout)
Phenytoin (Dilantin)

28. Items that may decrease
Coumadin effectiveness
Vitamin K Foods (dark green leafy
vegetables, brussels sprouts,
prunes)
High- Protein Diets
Trazodone
St. John’s Wart
Ranitidine
Omeprazole
Ginseng

29. Tobacco
May falsely increase or
decrease INR

30. Noni Juice
May cause an increase in
acquiring Warfarin/
Coumadin resistance.

31. So how is
Great-Aunt Bea?

32. She’s
good!

33. Thank you for your time!