Care Plan for Anticoagulant Use

Category / Primary Body System

• Hematologic System

Problem

• Anticoagulant use

Goal

• Resident will not exhibit signs of bleeding or bruising for the next 90 days.

Plan/Approach

1. Monitoring and Assessment

   • Monitor vital signs as ordered to detect any changes that might indicate bleeding or other complications.
   • Draw labs as ordered, monitor results, and report to the attending physician.
   • Monitor for signs of bleeding, including gums, sclera, bruising, and other areas.
   • Monitor for signs of Deep Vein Thrombosis (DVT), such as pain in the leg distal to the thrombus, unilateral swelling distal to the site, redness and warmth of the leg, dilated leg veins, low-grade fever, and positive Homan's sign.
   • Monitor for signs of pulmonary embolus, including pleuritic chest pain, dyspnea, tachypnea, apprehension, cough, hemoptysis, crackles, tachycardia, fever, diaphoresis, and syncope.
   • Notify MD immediately if signs of DVT or pulmonary embolism are noted.

2. Medication Management

   • Adjust dosage per MD order to ensure effective anticoagulation while minimizing the risk of bleeding.

3. Safety Measures

   • Encourage the use of an electric razor to prevent cuts and nicks.
   • Encourage the use of a soft toothbrush and a gentle brushing technique to prevent gum bleeding.

4. Patient Education

   • Provide education on monitoring for signs of bleeding and bruising and the importance of reporting these signs immediately.
   • Teach the patient and family about the signs of DVT and pulmonary embolus and the importance of reporting these symptoms immediately.

5. Activity and Exercise

   • Encourage range of motion exercises with care to prevent complications such as DVT without causing injury.

Rationale

1. Monitoring and Assessment

   • Regular monitoring of vital signs and lab results helps detect early signs of bleeding or other complications, allowing for prompt intervention.
   • Monitoring for signs of DVT and pulmonary embolism ensures early detection and treatment, reducing the risk of severe complications.

2. Medication Management

   • Proper dosage adjustments based on medical orders help maintain therapeutic anticoagulation levels, minimizing the risk of bleeding.

3. Safety Measures

   • Using an electric razor and a soft toothbrush reduces the risk of cuts and bleeding, which are significant concerns for patients on anticoagulants.

4. Patient Education

   • Educating the patient and family empowers them to participate in monitoring for complications and ensures prompt reporting of any issues.

5. Activity and Exercise

   • Encouraging safe exercise helps maintain circulation and prevent DVT without causing harm.

Actions

1. Monitoring and Assessment

   • Record vital signs as ordered, noting any abnormalities.
   • Collect lab samples as ordered, monitor results, and communicate findings to the physician.
   • Inspect for signs of bleeding during routine care and document any findings.
   • Assess for DVT and pulmonary embolism symptoms during regular check-ups and document findings.
   • Report any signs of DVT or pulmonary embolism to the MD immediately.

2. Medication Management

   • Administer anticoagulant medications as prescribed, ensuring adherence to dosage adjustments.
   • Monitor for and document any side effects or complications from anticoagulant therapy.

3. Safety Measures

   • Instruct the patient to use an electric razor for shaving.
   • Provide a soft toothbrush and demonstrate gentle brushing techniques to the patient.

4. Patient Education

   • Teach the patient and family to monitor for signs of bleeding, DVT, and pulmonary embolism.
   • Provide written and verbal instructions on the importance of reporting any symptoms immediately.

5. Activity and Exercise

   • Assist the patient with range of motion exercises, ensuring they are done safely and effectively.