Warfarin, a GI Bleed, and a New NSAID Order
Mr. R, 68, is admitted with a 3-day history of dark, tarry stools and epigastric pain. His home medications include warfarin 5 mg PO daily for atrial fibrillation, metoprolol, and omeprazole. Admission labs: Hgb 9.4 g/dL (his baseline two months ago was 12.0), platelets 180,000, INR 4.8.
The provider's new orders are:
- Warfarin 5 mg PO daily, continue home dose
- Ketorolac 30 mg IV every 6 hours PRN for pain
- Ferrous sulfate 325 mg PO daily
- Type and screen; repeat CBC in the morning
Mr. R rates his epigastric pain 6/10 and tells you, "The pills I got last time worked great - just give me the strong stuff."
1. Which ordered medication do you question before giving, and what is your rationale?
Read the worked answer
Question the ketorolac.
- It is an NSAID, and NSAIDs inhibit platelet aggregation and irritate gastric mucosa - exactly the wrong drug for a client who is actively bleeding from the upper GI tract and already anticoagulated.
- Combined with warfarin, the bleeding risk is additive; with a falling Hgb (12.0 to 9.4) and an INR of 4.8, this client is already in a dangerous place.
- NSAIDs can also displace warfarin from protein binding and further raise the INR.
- His pain needs to be managed - that part of his request is legitimate - so advocate for an alternative (e.g., acetaminophen if the provider approves), not simply withholding relief.
Also question the continued warfarin dose with an INR of 4.8 plus active bleeding; expect the provider to hold it and possibly order vitamin K. The nurse's job is to clarify, not to silently administer or to unilaterally rewrite the plan.
2. It is 2200 and the warfarin is due. What do you do, and what do you document?
Read the worked answer
Hold the dose and call the provider now - do not wait until morning.
Steps:
- Verify the INR result against the actual lab report (not a verbal value) and check for any other bleeding (gums, urine, stool, IV sites, neuro status).
- Withhold the warfarin. An INR of 4.8 exceeds a typical therapeutic range of 2-3 for atrial fibrillation and is above the usual threshold at which a dose is held.
- Notify the provider with the specifics: INR 4.8, Hgb 9.4 and falling, melena, and the ketorolac order - and ask for direction on vitamin K, repeat INR, and the analgesic plan.
- Implement bleeding precautions: fall precautions, soft toothbrush, no razors, avoid IM injections, pressure to puncture sites, monitor for headache or back pain suggesting retroperitoneal bleed.
- Document the held dose, the time and content of the notification, the provider's response, and the client's status.
Do not "give it anyway because it was ordered" and do not hold it silently without notification - both are unsafe for opposite reasons.
3. What will you teach Mr. R before discharge to reduce his risk of another bleed?
Read the worked answer
Teach in plain language, check understanding by having him state it back, and include the family member who shops and cooks for him.
- Report, don't wait: black or bloody stools, vomiting blood or "coffee grounds," pink or brown urine, unusual bruising, nosebleeds that will not stop, severe headache, or a fall with a head strike.
- Avoid NSAIDs and aspirin unless the provider specifically approves; read labels on over-the-counter cold, pain, and "stomach" products.
- Keep vitamin K intake steady (leafy greens) rather than eliminating them - consistency is what matters with warfarin.
- No alcohol binges; limit as directed.
- Keep every INR appointment and carry medical-alert identification.
- Bleeding precautions at home: soft toothbrush, electric razor.
- Iron supplement teaching: take with vitamin C or juice, expect dark stools (do not confuse with melena), and separate it from certain other medications as directed.
The teach-back matters more than the handout: ask him to name two symptoms that would send him to the emergency department.