Carly D’Agostino, #107, Thromboembolic Disease
Pt Name/ID: TB Age: 61 yo Wt: 85kg Ht: 64” = 164.6 cm IBW: 54.7 kg Clcr, estimated: 46.6mL/min Allergies / Soc Hx: sulfa; retired elementary teacher; normal BS
Problem Prioritization: 1) Thrombus prophylaxis initiation
SUBJECTIVE/
OBJECTIVE
none
EVIDENCE
SUBJECTIVE:
- mother died of
a stroke at age
62
ETIOLOGY:
- pt is entering into
a high risk surgery
and needs to have
appropriate DVT
prophylaxis after
surgery
CONTRIBUTING
FACTORS:
- PMH indicates
previous stroke
EVIDENCE
OBJECTIVE:
- PMH: stroke
- admitted to the
hospital’s
orthopedic
service for an
elective RTHA
PROBLEM:
Treatment
initiation
3) Follow up INR
ASSESSMENT
Subjective
Current
Etiology;
& Objective Evidence Medications Risk Factors / Contributing
Factors
PROBLEM:
Thrombus
prophylaxis
initiation
2) Treatment Initiation
Evaluate Need For Therapy;
Evaluate Current Therapy
Evaluate Treatment Options
EVALUATE NEED FOR THERAPY:
- due to pt’s high risk surgery for thrombosis, pt needs to be started on a
prophylaxis therapy immediately after surgery to prevent a potential clot,
especially a pulmonary embolism
- prophylaxis therapy is necessary but no bridging is needed in these pts
EVALUATE CURRENT THERAPY:
- ibuprofen 800mg q8hrs prn pain: due to its antiplatelet effect, it would be
appropriate to discontinue this agent before surgery because it may cause the
pt to bleed more; also it would appropriate to discontinue this agent after the
surgery because pt is already on hydrocodone/acetaminophen for pain
- D/C ibuprofen
- clopidogrel: antiplatelet therapy should be discontinued before surgery so pt
doesn’t increase her risk of bleeding during surgery. However it can be
restarted after surgery.
- D/C clopidogrel, but can be restarted after surgery
EVALUATE TREATMENT OPTIONS:
- pt is considered in high risk because she will be undergoing a hip arthroplasty
- according to CHEST guidelines, LMWH or fondaparinux or vitamin K
antagonist with a goal INR of 2-3 is recommended
- LMWH: excellent inhibitors of Factor Xa; does not inhibit thrombin as well as
heparin; appropriate because of simplified dosing, improved SQ
bioavailability, predictable response, less lab monitoring, pt can selfadminister, especially important if pt is going home soon after surgery
- start enoxiparin 30mg SQ BID for at least 10 days: appropriate dosage
for prophylaxis for high risk patients according to CHEST guidelines;
inappropriate for patient because of two injections every day
- fondaparinux: selective inhibitor of factor Xa; appropriate because of
simplified dosing, routine coagulation monitoring not recommended,
predictable response, pt can self-administer
- start fondaparinux 2.5mg SQ q24hours for at least 10 days: appropriate
dosage for prophylaxis according to CHEST guidelines; most appropriate
because only once-a-day dosing
- vitamin K antagonist (warfarin): appropriate because effective
anticoagulant; inappropriate because full effect is not seen for 3-5 days and
this patient needs immediate effect for prophylaxis after surgery;
inappropriate because dosing is very patient specific and not as simplified as
other agents
fondapari
nux
Care Plan Format 8/16/06 ta salazar
ETIOLOGY:
- embolism formed
in lungs following
EVALUATE NEED FOR THERAPY:
- all signs and symptoms indicate pulmonary embolism which requires
immediate drug therapy to treat the current condition and prevent a fatal attack
PLAN
Goals Of Therapy;
Recommended Drug or Nondrug
Treatment; Drugs To Be Avoided
Further Tests & Plans
Therapeutic &Toxic
Monitoring Parameters
GOALS OF THERAPY:
- prevent any thrombus
formation in the body (DVT
or PE)
- prevent any bleeding
episodes during or after
surgery
- INR: 2-3
FURTHER TESTS
& PLANS:
- monitor CBC and
signs of bleeding
every day while pt is
in the hospital
- monitor CrCl daily
while in hospital
- verify INR is in
goal range (2-3)
RECOMMENDED
DRUG TREATMENT:
- D/C ibuprofen
- D/C clopidogrel, but can
be restarted after surgery
- fondaparinux (Arixtra)
2.5mg SQ q24hours for at
least 10 days
DRUGS TO BE
AVOIDED:
GOALS OF THERAPY:
- resolve PE
- relieve shortness of breath
THERAPEUTIC
MONITORING
PARAMETERS:
- monitor for
absence of clots and
absence of bleeding
episodes
TOXIC
MONITORING
PARAMETERS:
- monitor for
decreased platelet
levels and signs of
bleeding
FURTHER TESTS
& PLANS:
- monitor CBC and
Patient
Education
- explain to patient that before
her surgery both ibuprofen and
clopidogrel needs to be
stopped in order to decrease
the risk of bleeding during her
surgery
- inform the patient that after
her surgery she will be started
on a drug therapy called
fondaparinux which will be
injected every day in order to
prevent any blood clots from
forming which could lead to
complications
- instruct pt on how to inject
fondaparinux every day:
- wash hands and wipe
injection site with an alcohol
swab
- pinch an area of fat on the
lateral sides of the belly button
- needle should be injected at a
90o angle and should take 2-3
seconds
- site should be rotated about
the abdomen but do not rub
because it will cause bruising
- pushing plunger again after
administering drug will eject a
safety barrel
- properly dispose in sharps
container or a hard milk or
detergent container
- contact PCP if you
experience chest pains,
shortness of breath, or
bleeding episodes for it may
indicate a clot or excessive
bleeding and a necessary
change in therapy
- consult PCP or pharmacist
before starting any new
medications
- explain to the patient that the
cause of her shortness of
breath is that a clot has formed
Carly D’Agostino, #107, Thromboembolic Disease
SUBJECTIVE/
OBJECTIVE
ASSESSMENT
Subjective
Current
Etiology;
& Objective Evidence Medications Risk Factors / Contributing
Factors
EVIDENCE
SUBJECTIVE:
- complaints of
shortness of
breath 3 days
after RTHA
surgery
2.5mg
SQ q24
hours
EVIDENCE
OBJECTIVE:
- spiral CT scan:
(+) for PE
the pt’s RTHA
surgery probably
due to immobility
after surgery
CONTRIBUTING
FACTORS:
Evaluate Need For Therapy;
Evaluate Current Therapy
Evaluate Treatment Options
- adjusting current medications as well as adding new anticoagulant drugs is
necessary to treat the PE
EVALUATE CURRENT THERAPY:
- fondaparinux 2.5mg SQ q24 hours: appropriate for prophylaxis therapy for
DVT and PE; inappropriate dosage for the treatment of PE
- D/C fondaparinux 2.5mg SQ q24hours
- St. John’s Wort daily: inappropriate to be continued once warfarin therapy
has begun because it is a potent inhibitor of CYP3A4 and potentially 2C9;
drugs that inhibit 3A4 and 2C9 decrease warfarin’s metabolism and leads to an
increased INR and thus increased risk of bleeding
- D/C St. John’s Wort
- clopidogrel 75mg po daily: appropriate to restart antiplatelet therapy after
surgery because now after surgery there is a greater risk of clotting rather than
an increased risk of bleeding during surgery
EVALUATE TREATMENT OPTIONS:
- since the pt now has been diagnosed with PE, she needs to be treated as such
- according to CHEST guidelines, treatment of PE includes initiation of
treatment doses of anticoagulants, either UFH, fondaparinux, or LMWH, and
then initiation of the oral anticoagulant warfarin
- because warfarin does not have its full therapeutic effect for 3-5 days, both
medications need to be started in order to bridge therapy until warfarin begins
to work
- UFH: appropriate because of low cost and useful for obese patients;
inappropriate because administered IV which would not be appropriate for
home use and aPTT needs to be monitored every 6 hours until therapeutic range
is reached; in addition there is a need to calculate when to initiate therapy after
fondaparinux is discontinued
- fondaparinux: appropriate because patient is currently on fondaparinux for
prophylaxis and can be started immediately rather than calculating half-life for
time of initiation; also, simplified dosing, routine coagulation monitoring not
recommended, more predictable response than heparin, and patient can selfadminister
- start fondaparinux 7.5mg SQ q24hours, continue at least 5 days and
until INR > 2 for 24 hrs: appropriate dosage for treatment of PE
- LMWH (enoxaparin): appropriate because of simplified dosing, improved
SQ bioavailability, predictable response, less lab monitoring, pt can selfadminister, especially important if pt is going home soon after surgery;
inappropriate because it is necessary to calculate when to initiate therapy after
fondaparinux is discontinued
- warfarin: effectively binds and inactivates thrombin and clotting factor Xa
which have major roles in the clotting cascade
- start warfarin 5mg po daily for 3 months: appropriate initial dosage for
anticoagulant treatment of 1st episode of PE
Care Plan Format 8/16/06 ta salazar
PLAN
Goals Of Therapy;
Recommended Drug or Nondrug
Treatment; Drugs To Be Avoided
- prevent future
complications and future
embolisms
- INR: 2-3
RECOMMENDED
DRUG TREATMENT:
- D/C St. John’s Wort
- restart clopidogrel 75mg
po daily
- D/C fondaparinux 2.5mg
SQ q24hours
- fondaparinux (Arixtra)
7.5mg SQ q24 hours,
continue at least 5 days and
until INR > 2 for 24 hrs
- warfarin 5mg po daily for
3 months
DRUGS TO BE
AVOIDED:
Further Tests & Plans
Therapeutic &Toxic
Monitoring Parameters
Patient
Education
signs of bleeding
daily while in
hospital
- monitor INR after 3
doses of warfarin
- Then monitor INR
every day while in
the hospital until
INR> 2 for at least
24 hours
- once pt has been on
fondaparinux for 5
days and has INR >
2 for 24 hours, stop
fondaparinux
- follow up with PCP
or Coumadin Clinic
to monitor INR
every week until
stable (goal INR = 23)
- Then monitor every
4 weeks once INR is
stable
- if pt has stable INR
for 3 months on
warfarin, then
medication can be
stopped
in her lungs as a result of the
surgery and her
immobilization in the hospital
- in order to treat her
condition, we need to continue
one of her medications as well
as add on warfarin to be taken
every day
- emphasize the importance of
taking warfarin every day
because it is needed to keep
her blood from clotting
- explain to patient that she
will only be using
fondaparinux until her blood
tests indicate that they are in
goal range
- see above for administration
of fondaparinux
- upon discharge from
hospital, educate patient on
warfarin therapy:
- signs and symptoms of
bleeding such blood in stool
and urine
- signs and symptoms of a
clot, such as swollen, red leg,
shortness of breath and chest
pain
- inform all healthcare
providers that she is on
warfarin and adjust any future
medications accordingly
- continue eating healthy
foods, just eat consistently
- consult the warfarin
handbook for specifics on
dietary modifications
- use caution on alcohol intake
because that can change
warfarin’s effect
- become familiar with tablet
color and size in order to
recognize and verify it upon
refills
- if a dose is missed, take it as
soon as remembered but do
not double up on a dose
- remember to keep up with
INR monitoring and
THERAPEUTIC
MONITORING
PARAMETERS:
- monitor for
absence of
embolisms and INR
to be in the range of
2-3 for 24 hours
while on
fondaparinux and
then discontinue
TOXIC
MONITORING
PARAMETERS:
- monitor for
decreased platelets,
signs of bleeding,
signs of clotting and
INR out of the 2-3
Carly D’Agostino, #107, Thromboembolic Disease
SUBJECTIVE/
OBJECTIVE
ASSESSMENT
Subjective
Current
Etiology;
& Objective Evidence Medications Risk Factors / Contributing
Factors
PROBLEM:
Follow up INR
- warfarin
7.5mg po
daily
EVIDENCE
SUBJECTIVE:
- pt reports no
complaints with
her warfarin
therapy
- states she has
been doing
“great”
EVIDENCE
OBJECTIVE:
- INR has been
therapeutic her
last 2 visits
- ↓current INR:
1.6
ETIOLOGY:
Unknown
CONTRIBUTING
FACTORS:
- previous PE
Evaluate Need For Therapy;
Evaluate Current Therapy
Evaluate Treatment Options
EVALUATE NEED FOR THERAPY:
- present INR levels indicate that the goal INR between 2 and 3 is not reached
and therefore unstable, so current warfarin dosage needs to be adjusted
immediately in order to increase the INR within goal
- adjusting the warfarin dose is necessary to prevent future PEs and DVTs and
other potentially fatal complications
EVALUATE CURRENT THERAPY:
- warfarin 7.5mg po daily: according to pt’s previous visits, this dosage was
effectively controlling the patient’s INR levels; however today according to
patient’s decreased INR, warfarin dosage must be adjusted
EVALUATE TREATMENT OPTIONS:
- according to CHEST guidelines, warfarin dosage should be adjusted if the
pt’s INR is 1.6 by increasing the total weekly dose by 10-15%
- D/C warfarin 2.5mg po daily
- start warfarin 8.5mg po daily: appropriate dosage, see calculations below
PLAN
Goals Of Therapy;
Recommended Drug or Nondrug
Treatment; Drugs To Be Avoided
GOALS OF THERAPY:
- prevent future PE and
DVT and other
complications
- INR: 2-3
- prevent hemorrhage or
other bleeding episodes
RECOMMENDED
DRUG TREATMENT:
- D/C warfarin 7.5mg po
daily
- warfarin 8.5mg po daily
DRUGS TO BE
AVOIDED:
Further Tests & Plans
Therapeutic &Toxic
Monitoring Parameters
range
appointments in order to
prevent bleeding or clotting
episodes
- contact PCP if experiencing
shortness of breath, chest pain,
or bleeding
- consult PCP or pharmacist
before starting any new
medications to see if they
interact with warfarin
FURTHER TESTS
& PLANS:
- follow up with PCP
or Coumadin Clinic
in one week to check
INR and then every
4 weeks once stable
- continue warfarin
therapy for 1 month
as long as INR is
within goal range
- explain to patient that due to
her blood levels today, her
warfarin dose will be
increased in order to prevent
future embolisms and other
complications and to get her
INR back in goal range
- inform patient she will be
taking 1-7.5mg tablet as well
as 1-1mg tablet every day
- emphasize the importance of
taking warfarin every day
because it is needed to keep
her blood from clotting
- educate pt on warfarin
therapy (see above)
- encourage INR scheduled
appointments to monitor her
levels and make sure other
adjustments are taken care of
- contact PCP immediate if
experiencing shortness of
breath, chest pain or bleeding
- consult PCP or pharmacist
before starting any new
medications
THERAPEUTIC
MONITORING
PARAMETERS:
- monitor for
absence of
embolisms and INR
to be in the range of
2-3
TOXIC
MONITORING
PARAMETERS:
- monitor for
decreased platelets,
signs of bleeding,
signs of clotting and
INR out of the 2-3
range
IBW = 45.5 + (2.3 x 3) = 52.4kg
CrCl = (140-57)(52.4)/(72)(1) X 0.85 = 51.3mL/min
Total weekly dose: 7.5mg x 7days = 52.5mg
Increase dose by 10-15%: 52.5mg x 10-15% increase = 57.75mg – 60.375mg
57.75/7days = 8.25mg
Care Plan Format 8/16/06 ta salazar
Patient
Education
Carly D’Agostino, #107, Thromboembolic Disease
Care Plan Format 8/16/06 ta salazar