Supratherapeutic INR With a New NSAID Order
Mrs. L, 74, weighing 54 kg, is admitted with a 2-day history of a swollen, painful right knee. She has atrial fibrillation and takes warfarin 5 mg daily; her INR today is 5.6 (target 2.0–3.0) and was 2.4 one week ago. She has no visible bleeding but reports bruising on both forearms and dark, tarry stools for 2 days. Her last warfarin dose was 26 hours ago. BP 128/76, HR 88, respirations 18. The hospitalist has ordered: warfarin 5 mg PO now; ketorolac 30 mg IV every 6 hours as needed for pain; cephalexin 500 mg PO every 8 hours; omeprazole 20 mg PO daily; and acetaminophen 650 mg PO every 6 hours as needed. She tells you, "I've been eating a lot of spinach lately because my neighbor said it's good for my blood."
1. Which of these orders will you give, which will you hold, and what will you tell the provider?
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Give cephalexin and omeprazole. Acetaminophen may be given as ordered for pain, keeping within the daily maximum.
Hold warfarin. An INR of 5.6 with new melena and unexplained bruising suggests supratherapeutic anticoagulation with possible GI bleeding; giving the next dose worsens risk, and the prescriber must decide on vitamin K and repeat testing. Do not give vitamin K on your own - it requires an order.
Hold ketorolac and question the order. It is an NSAID in a patient already anticoagulated, aged over 65, with possible GI bleeding and likely reduced renal function; the 30 mg IV dose also exceeds the reduced 15 mg dose generally recommended for patients over 65. Give neither the warfarin nor the ketorolac without clarification.
SBAR to the provider: "Mrs. L's INR is 5.6, up from 2.4, with 2 days of dark tarry stools and forearm bruising. I am holding warfarin and ketorolac. Do you want a stat CBC, repeat INR, stool testing, vitamin K, and a different analgesic?" Document the hold and the notification.
2. What assessments will you perform now and what will you monitor over the next 12 hours?
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Do a head-to-toe bleeding survey: skin and mucous membranes for petechiae and bruising, gums and nares, IV sites, urine and stool color, and any pain in the joints, back, or abdomen that could signal retroperitoneal bleeding. Assess neurologic status and ask about headache - intracranial bleeding is the most feared complication and can present subtly. Check vital signs for orthostatic changes and tachycardia, which may be the first sign of a GI bleed before hemoglobin falls.
Over 12 hours, monitor vital signs with orthostasis, repeat INR and hemoglobin/hematocrit, platelets, and renal function; track stool and urine output and report any recurrence of melena. Institute bleeding precautions: fall precautions, no IM injections, no rectal temperatures or suppositories, soft toothbrush, electric razor, and careful IV removal with prolonged pressure. Reassess the knee for warmth and swelling. Report any new bleeding, dizziness, or change in mental status immediately.
3. What will you teach Mrs. L before discharge about warfarin and her diet, and how do you respond to the spinach comment?
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Explain that the goal is consistency, not avoidance. Spinach is high in vitamin K, and a sudden large increase can lower the INR - but cutting it out entirely, or swinging back and forth, makes control harder. Tell her to keep her intake of leafy greens roughly steady from week to week and to tell the provider if her diet changes substantially. Never change her own dose to compensate.
Other teaching: take warfarin at the same time daily and keep all INR appointments; avoid over-the-counter NSAIDs and aspirin, and check with the pharmacist before any new drug or herbal product (ginkgo, St. John's wort, and fish oil all matter); limit alcohol; use a soft toothbrush and electric razor; wear a medical alert bracelet.
Teach when to call: black or bloody stools, vomiting blood or coffee-ground material, nosebleeds that will not stop, unusual bruising, pink or red urine, or any head injury - even if she feels fine after a fall. Ask her to repeat back the plan.