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Azith
- 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 Beahas: CHF Controlled A-Fib Diabetes, Non-Insulin Dependent A Recent Diagnosis of Pneumonia
- 4. Her Medications Great-Aunt Beatakes: Albuterol Inhaler Coumadin Furosemide Metformin Azithromycin (for the Pneumonia)
- 5.
- 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 looksuncomfortable. 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 theNurse do?
- 9. Do an EKG Shehas a History of A-Fib, the Doctor will want one.
- 10. Get a urinesample. 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.
- 14. Everything is normal on her labs, except..... Great-Aunt Bea’s INR is 13!!!!
- 15. Why is 13a 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 wasGreat-Aunt Bea’s so high?
- 17. Here’s why... According toMicromedex, found on the Pulse Page “Concurrent use of AZITHROMYCIN and WARFARIN may result in an increased risk of bleeding.”
- 18. The “Probable Mechanism” accordingto Micromedex The disruption of vitamin K synthesis
- 19. So now whatdoes 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 thatshe has, at least, a 20 gauge IV for receiving blood products. Also, avoid multiple blood draws and IV starts.
- 21. MAKE HER AFALL RISK!!!
- 22. If not alreadydone 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 Accordingto Lexi-Drugs, found on the Pulse Page INR >10 with no evidence of bleeding Administer oral Vitamin K
- 24. Again, according toLexi- Drugs INR >10 with minor bleeding Administer oral vitamin K more frequently
- 25. Major bleeding atany INR elevation Administer IV vitamin K Prepare to give Fresh Frozen Plasma
- 26. Other Interactions withCoumadin 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 maydecrease 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 increaseor decrease INR
- 30. Noni Juice May causean increase in acquiring Warfarin/ Coumadin resistance.
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- 33. Thank you foryour time!