Injection Visit With an Elevated INR and New Allergy
A 71-year-old woman arrives for a scheduled intramuscular influenza vaccination and a vitamin B12 injection. She reports starting warfarin 3 weeks ago and gives a recent INR of 3.8. She also reports a new 'egg allergy' that causes hives after eating scrambled eggs, and she takes ibuprofen 400 mg twice daily for knee pain. The orders are current and signed. The clinic protocol requires the MA to review allergies and medications before injection and to notify the provider of any INR above the ordered threshold. The patient says she feels fine and does not want to reschedule. She has a history of atrial fibrillation and no bleeding gums or bruising. The MA has not yet administered either injection. The vitamin B12 order specifies 1,000 mcg IM.
1. What concerns should the MA identify before administering either injection, and what should happen next?
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Three concerns stand out. First, an INR of 3.8 is above the usual therapeutic range and above the ordered threshold, so the MA must notify the provider before any IM injection because of bleeding risk. Second, ibuprofen twice daily further increases bleeding risk. Third, the reported egg allergy with hives should be clarified, although current guidance does not contraindicate influenza vaccination for egg allergy.
The MA should hold both injections, notify the provider with the INR, medication, and allergy details, and ask whether to proceed, delay, or refer. Do not administer the vaccine and then report. The patient's statement that she feels fine does not override the protocol threshold. Document the notification time and the provider's response before acting.
2. If the provider clears the injections, what technique reduces bleeding risk?
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Use the smallest appropriate needle that reaches the muscle; for this patient, a 23-25 gauge, 1-1.5 inch needle may be appropriate depending on site and body mass. Use the deltoid for the influenza vaccine; vitamin B12 can be given in the deltoid or ventrogluteal site per order. Apply firm pressure without massage for at least 2-5 minutes, longer if bleeding persists. Do not aspirate.
Use a new needle and syringe for each injection, and separate sites by at least 1 inch if both are in the same deltoid. Inspect for bruising or hematoma. Document the site, needle length and gauge, lot numbers, and pressure time. If bleeding is prolonged, notify the provider.
3. What patient education and documentation are required?
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Teach the patient to report signs of bleeding-an expanding bruise, swelling, pain, or prolonged oozing-and to avoid rubbing the site. Reinforce that ibuprofen increases bleeding risk and that she should ask the provider about alternatives. Explain that egg allergy with hives does not usually prevent influenza vaccination but that she should remain for 15-30 minutes for observation per protocol.
Document the INR value and source, provider notification and response, allergy clarification, consent, injections given with lot and site, observation time, and education. If the provider delays the injections, document the reason and the rescheduled plan.