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Chapter 27 Drugs for Coagulation Disorders 385

NURSING PROCESS FOCUS Clients Receiving Anticoagulant Therapy

Assessment Potential Nursing Diagnoses
Prior to administration: ■ Injury, Risk for (bleeding), related to adverse effects of anticoagulant therapy
■Obtain a complete health history including recent surgeries or trauma, ■ Activity Intolerance (Contact Sports)
allergies, drug history, and possible drug interactions. ■ Tissue Perfusion, Ineffective, related to hemorrhage
■Obtain vital signs and assess in context of client’s baseline values. ■ Tissue Integrity, Impaired
■ Infection, Risk for
■ Knowledge, Deficient, related to drug therapy
Planning: Client Goals and Expected Outcomes
The client will:
■Experience a decrease in blood coagulation as evidenced by laboratory values.
■Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions.
Implementation
Interventions and (Rationales) Client Education/Discharge Planning
■ Monitor for adverse clotting reaction(s). (Heparin can cause thrombus forma- Instruct client to:
tion with thrombocytopenia, or “white clot syndrome.” Warfarin may cause ■ Immediately report sudden dyspnea, chest pain, temperature or color change
cholesterol microemboli that result in gangrene, localized vasculitis, or in the hands, arms, legs, or feet.
“purple toes syndrome.”)
■ Observe for skin necrosis, changes in blue or purple mottling of the feet that Instruct client to:
blanches with pressure or fades when the legs are elevated. (Clients on antico- ■ Check pulses in the ankle daily.
agulant therapy remain at risk for developing emboli resulting in CVA or PE.) ■ Protect feet from injury by wearing loose-fitting socks; avoid going barefoot.
■ Use with caution in clients with GI, renal and/or liver disease, alcoholism, ■ Instruct elderly clients, menstruating women, and those with peptic ulcer
diabetes, hypertension, hyperlipidemia, and in the elderly and premenopausal disease, alcoholism, or kidney or liver disease that they have an increased risk
women. (Clients with CAD, diabetes, hypertension, and hyperlipidemia are at of bleeding.
increased risk for developing cholesterol microemboli.)
■ Monitor for signs of bleeding: flulike symptoms, excessive bruising, pallor, Instruct client to:
epistaxis, hemoptysis, hematemesis, menorrhagia, hematuria, melena, frank ■ Immediately report flulike symptoms (dizziness, chills, weakness, pale skin);
rectal bleeding, or excessive bleeding from wounds or in the mouth. (Bleeding blood coming from a cough, the nose, mouth, or rectum; menstrual “flood-
is a sign of anticoagulant overdose.) ing”; “coffee grounds” vomit; tarry stools; excessive bruising; bleeding from
wounds that cannot be stopped within 10 minutes; all physical injuries.
■ Avoid all contact sports and amusement park rides that cause intense or
violent bumping or jostling.
■ Use a soft toothbrush and an electric shaver.
■ Monitor vital signs. (Increase in heart rate accompanied by low blood pressure ■ Instruct client to immediately report palpitations, fatigue, or feeling faint,
or subnormal temperature may signal bleeding.) which may signal low blood pressure related to bleeding.
■ Monitor laboratory values: aPTT and PTT for therapeutic values. (Heparin may Instruct client to:
cause significant elevations of aspartate aminotransferase (AST) and alanine ■ Always inform laboratory personnel of heparin therapy when providing
transaminase (ALT), because the drug is metabolized by the liver.) samples.
■ Carry a wallet card or wear medical ID jewelry indicating heparin therapy.
■ Monitor CBC, especially in premenopausal women. (Changes in CBC may ■ Instruct client to keep a “pad count” during menstrual periods to estimate
indicate excessive bleeding.) blood losses.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see “Planning”).
■The client’s laboratory values exhibit a decrease in blood coagulation.
■The client demonstrates an understanding of the drug’s action by accurately describing drug side effects and precautions.
See Table 27.2 for a list of drugs to which these nursing actions apply.